Your turn to tell us about you:

Intake Form- Please fill out completely and bring to initial consultation

Parent’s  Name: ______________________________________________ 

Address: ______________________________________________ 

Cell Phone: _____________________ 

Times: _______ am _______ pm 

Email address: ______________________________________________ 

 Marital Status: Married ____Divorced ____Single ____Separated ___ Significant Other ____Widowed ____ Occupation: _____________________________

 

Child’s Information:

DOB: __________ Age: _____ Grade: __________ 

 

Others living in the household:

Name: ______________________________ Age: _____ 

Relationship to Child:__________________

Grade or Occupation:________________________ 

 

Name: ______________________________ Age: _____ 

Relationship to Child:____________________ 

Grade or Occupation:________________________ 

 

Biological Parent Outside the Household : 

If different from above, please give; 

Biological Mother’s name: ______________________________________________ 

Biological Father’s name: ______________________________________________

 

 

Honesty is key. Please answer the following questions truthfully. The fact that you are asking for help shows how much you love your child and we are not here to judge. Your answers will only be used as a tool to give the best possible outcome and will be kept completely confidential.

 

What issues or concerns would you like to address in these coaching sessions? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

What would you say is your biggest parental concern? ___________________________________________________________________________________________________________________________________________________________________________________ 

 

List any hesitations you may have about starting a coaching plan __________________________________________________________________________________________

 

What is your current discipline techniques and do you find it working? ____________________________________________________________________________________________________________________________

Are you and your spouse (or significant other) on the same page when it comes to discipline?_____________________________________________________________

 

How many hours a day is your child on their device(s) or video games __________________________

 

 

What would you say is the main source of strain in your family? __________________________________________________________________________________________________________________________________________________________________________________________________________________ 

 

Has their been any changes in your household over the last year? If yes, please explain. _____________________________________________________________________________________________________________________________________________________________________________________________________________ 

 

Tell me a few interesting facts about your child. (ie. disposition and personality) _______________________________________________________________________________________________________________________________________________________________________________________ 

 

 

 

Parent coaching is not therapy. We cannot diagnose your child nor advise any type of medical treatment. Parent coaching is a learning tool for parents to help provide the support needed during challenging times. I hereby consent  to weekly or bi-weekly sessions. All appointments will be agreed to by  parent(s) and Coach and will be kept confidential. Payments will be made at the end of each appointment. Texting, phone calls, and email are welcome following the sessions. All parties must agree to coaching as indicated below by your signature and date below. 

 

Print Name: (Parent) ______________________________

 

Date: ______________ 

 

Signature: _____________________________

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