Sports Intervention

I understand and acknowledge that all information on this form and future calls are confidential. *

Yes

No

Athlete's Phone

(###)

###

####

Check which statement(s) apply:

We want to play much better on this team

We want to get out of the current rut

We want to play Varsity Sports

We want to play College Sports

We want to play Professional Sports

If anything else, list in specific goals

Most accurate description of current state for athletics

Need much better performance for games

Need fast track to get back in the game

Need better performance for recruiting

Near crises mode--HELP

Athlete might not want to talk

Is your athlete currently involved with marijuana, vaping or any illegal drugs?

Yes

No

Possibly

Not sure

Sensory Areas of Concern:

Too much social media

Too much video gaming

Too much TV/Movie watching

Too much phone time

Too much time on school work

Preferred Communication with Athlete

Phone

Facetime

GotoMeeting on Laptop

Nocatee, Florida

Managing Parent's Name

Main parent managing athlete. Coach J's parental contact

First Name

Last Name

Managing Parent's Phone

(###)

###

####

Supportive Parent

Managing Parent's Spouse

First Name

Last Name

Supportive Parent Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I agree to counseling services at $120/hour, $75 1/2 hour, $35 for 15 mins or less to include Athlete Counseling, Parent Counseling, and attending events if needed. *

Agree

Disagree

To help my athlete improve their sports performance, I'm interested in:

Athlete Counseling and Coaching

Consulting on college recruitment

Parent counseling

1 Day Mental Performance Camp

We understand that Coach J’s counseling is very beneficial to athletes. We also understand that the Mental Performance Training can be a game changer for mental progress.

We understand and are interested in upcoming camps to jump start our athletes confidence and maturity.

We are not interested in upcoming camps

Payment Methods *

Venmo (send venmo friend request Coach Jay Holgate) @Jay-Holgate-1

Zelle (listed as Jay Holgate 404-597-4247)

Health Savings Account or (insurance debit card)

Credit card on file (add 3%)

Coach J Does Not Accept Insurance

So parents can have access to Coach J, I understand that every phone call with Coach J is billable time & pro rated. Texts are no charge. *

Agree

Disagree

New Client: $500 to get started & includes below. *

Step by Step

Account Set up

Application Review by Coach J

Parent in-take meeting with Coach J

Athlete meeting with Coach J

Priority Scheduling

I understand that pre-payment is required for new clients when 1st appointment is confirmed. *

Agree

Disagree

Scheduling is done through text on Sundays. I understand that Coach J stays booked and I agree that Same day cancellation is full fee. *

Agree

Disagree

I understand that Coach J cannot be held liable for any future actions by my child that result in injury, damages, financial and otherwise *

Agree

Disagree

Who participated in completing this form?

Athlete

Dad

Mom

Step parent

Coach/Trainer

Agent

Corporate sponsor

Other