Girl PowHer! Program

1-on-1 Life Coaching for Girls in St. Louis

New Client Intake Form

Welcome to the Girl PowHer Program, brought to you by Behind It All Foundation! We're dedicated to empowering young girls through personalized life coaching. If you're a girl aged 6 to 19 in St. Louis, this program offers exclusive 1-on-1 life coaching services.

Program Details:

Free Services: Thanks to our partnership with The St. Louis County Children's Services Fund (CSF), black girls ages 6-19 residing in Inner North County, St. Louis, can access our services absolutely free of charge.

Sliding Scale Fee Services: Girls aged 6 to 19 in the St. Louis metropolitan area can benefit from our program at a low sliding scale fee of $50 per session.

How to Join:

To become a new client, simply complete the form below, providing us with your details. Once submitted, your information will be reviewed by our admin team. If approved, we'll add you to our waitlist and a member from our team will reach out to you promptly for scheduling.

Thank you for expressing your interest in the Girl PowHer Program. We look forward to accompanying you on your journey of empowerment!

Tell us about YOU

Provide information about the person completing this intake form.

Who is completing this intake form? *

Which service type do you plan to use? *

How did you hear about Girl PowHer? *

I am seeking counseling for... *

Program Fee Eligibility

Help us determine your eligibility for our program. Black girls residing in inner north county are eligible for free services while all other young girls residing in St. Louis, MO are eligible for reduced fee at $50 a session. To be approved, you are required to select all options for either free or reduced fee to be eligible.

For free life coaching services, you consent to ALL of the following:
(you must check all to be eligible) *

You(th) identify as black or African American

You(th) identify as a girl or nonbinary

You(th) are between the ages 6-19 years

You(th) reside in Inner North County: 63074, 63114, 63120, 63121, 63133, 63134, 63135, 63136, 63137, 63140

For sliding scale life coaching services, you consent to ALL of the following:
(you must check all to be eligible) *

You(th) identify as a girl or non-binary

You(th) are between the ages of 6-19 years

You(th) reside in St. Louis, MO

Parent/Guardian Contact Information

Provide us with information about the parent/guardian of the youth. If you are a youth completing this form and do not want us to include your parents or cannot share their information for any reason, please input your contact information instead.

First name *

Last name *

Full Address (Street, City, State & Zip Code) *

Email address *

Phone number *

Best Ways To Reach You *

Phone Call	Text
Video	Email

Do you want to be a part of your child's life coaching journey? *

Yes

No

About the Client/Youth

Provide information about the youth who will be receiving our life coaching services.

First name *

Last name *

Full Address (Street, City, State & Zip Code) *

Phone number *

Email address *

Date of birth * +

Age *

Gender *

Have you/client ever had life coaching before? *

Yes

No

Do you want your parent(s) to be a part of your life coaching journey? *

Yes

No

Client/Youth School Information

School Name *

Current Grade *

Client/Youth Scheduling Preferences

Are you/client looking for telehealth (video chat) services? *

Yes, I prefer video chat sessions

Yes, I prefer to phone chat sessions

Yes, either phone and video chat

What is your/client scheduling availability for appointments? (select all that apply) *

Weekday Afternoons (2pm - 4pm)

Weekday Evenings (4pm - 6pm)

Are you comfortable with your/client life coach being female? *

Yes

No

Client/Youth Mental Health Background

Reason For Seeking Life Coaching *

What do you hope to experience in this life-coaching program? *

Give us some insight on client/youth mental health history. *

	Yes	Never	Currently
Youth ever experienced depression?	Yes	Never	Currently
Youth ever experienced anxiety?	Yes	Never	Currently
Youth ever attempted suicide?	Yes	Never	Currently
Youth ever experienced bullying?	Yes	Never	Currently

Additional Comments or Documents

Please use this space to share any additional comments, questions, or specific preferences regarding your (or your child) participation in the Girl PowHer program: *

Attachments - upload proof of address (of any type ie. school address, utility bill, ID, etc.):

Mental Health Supporter

Client processed by: (ENTER YOUR NAME) *

Date * +

Submission

By submitting this form, you acknowledge your interest in the Girl PowHer program by Behind It All Foundation and confirm that the information provided is accurate to the best of your knowledge.

Our Mission at Behind It All Foundation

Behind It All Foundation is dedicated to empowering underserved individuals and low-income communities through mental health and entrepreneurship, working to eliminate persistent inequities and foster lasting positive change.