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TEEN COACHING HEALTH FORM

This form helps ensure that coaching is safe, appropriate and supportive for your young person. Please complete as fully and honestly as possible.

All information is treated confidentially and stored securely.

Young Person’s Details

1. Physical Health

Does your young person have any diagnosed medical conditions that may affect participation in coaching?
Yes
No
Is your young person currently taking any medication?
Yes
No
Are there any recent illnesses, injuries or physical health concerns I should be aware of?
Yes
No

2. Mental & Emotional Wellbeing

Has your young person ever been diagnosed with a mental health condition?
Yes
No
Is your young person currently under the care of:
Has your young person experienced any of the following in the past 12 months?(Please tick any that apply)

3. SEND & Neurodiversity

Has your young person been diagnosed with or assessed for any of the following?
Does your young person have an EHCP?
Yes
No

4. Risk & Safeguarding Awareness

Are there any current safeguarding concerns I should be aware of?
Yes
No
Has your young person ever been subject to safeguarding intervention?
Yes
No

5. Additional Information

Declaration

I confirm that the information provided above is accurate to the best of my knowledge.

I understand that coaching is not a substitute for medical or therapeutic treatment and that I am responsible for informing the Coach of any significant changes to my young person’s health or circumstances.


Parent/Guardian Name:Signature:Date:

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Date
Day
Month
Year

© 2022 by GEMMA COUSINS, CÓRE COACHING

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