Intake Form

School Name

School Contact Name

School Contact Phone

School Contact Email

School Needs (check all that apply)
Professional Development (staff)After School (student)SEL (staff & student)General Wellness Programming (staff, family, and/or student)

Desired Outcomes (list 2-3 goals for the desired program)

Desired Program Format (check all that apply)
Student Wellness Class*In-Class SEL Coaching/Modeling*Teacher Wellness ClassParent Wellness ClassTeacher PD

Please indicate the grade level of students for any items marked with an asterisk (*) above

Desired Day of the Week (check all that apply)

Desired Time of Day
Before SchoolDuring SchoolAfter School

Unique Request/Comments Section