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FSF/Jane Coburn Life Coaching Application
Thank you for your application to Jane Coburn Life Coaching with Full Spectrum Farms. Life coaching is a partnership and we are looking for applicants that can commit to working towards their life goals over an 8 week coaching session. This will include a weekly meeting, phone call and homework! All applicants that are selected will be required to submit a reference.
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Email
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Your email
Name of Applicant:
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Birthdate:
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YYYY
Email address:
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Mailing address:
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Phone Number
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Parent/Guardian Name (Not applicable if you are your own guardian)
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Parent/Guardian Phone Number
Your answer
Does the applicant have a documented diagnosis of Autism Spectrum Disorder? A copy of diagnosis maybe requested.
yes
No
Clear selection
Please list any/all other forms of neurodiversity that the applicant has received a diagnosis for OR receives SSI, a 504 plan, an IEP plan or other forms of support for.
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What health care coverage do you have:
Medicaid
Private insurance
Option 3
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If applicant is a student, do they receive free/reduced lunch?
Yes
No
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Are you (the applicant) an SSI recipient?
Yes
No
Pending
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Is the applicant their own legal guardian?
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Median Household Income (If you are your own guardian you are a household of 1):
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Do you have access to the internet to support zoom calls?
Yes
No
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Do you have reliable transportation to meet the life coach at an agreed upon location?
Yes
No
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Please list the agencies that you are currently receiving support from:
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Why would you like to work with a neurodiversity life coach?
Your answer
What are your 3 top concerns that you want help with?
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Life coaching is a partnership. Each week the life coach will have homework that she will do and homework that you will need to complete. Tell us about your willingness to take suggestions and your ability to follow through with recommendations that she may have for you and your family:
Your answer
Please list someone in your life that can be a reference for you (teacher, former teacher, coach, employer, ect). Provide their name, phone number and email address below:
Your answer
All applicants will be required to submit the following upon request. Our staff will reach out to you to collect the support paperwork. Please check support paperwork that you will have access to:
Documentation of a Neuropsychological diagnosis
IEP from school officials
504 Educational Plan
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