Parenting Coaching Intake Form

Parenting coaching intake form

Please fill out the following sections as completely as possible.
Thank you for taking the time to fill out this form. Having this information prior to our first call helps us to utilize our time together more effectively and serve you better. If you have any questions, please do not hesitate to ask.
Please note, this information is private and will not be shared with any parties with out your express consent.

CONTACT INFORMATION

* Indicates required field

Name *

First

Last

Cellphone Number *

Email *

Ocuppation *

Preferred Form of Communication *

Email Phone call Text Message

How did you hear about us? If you were referred, please let us know so we can say thank you to them! *

PARENTING QUESTIONS

Why are you reaching out for support now? What is the immediate challenge? *

Your child's name, age, strengths and weaknesses. If you are not contacting me specifically about one child you can answer this question about each child in your family. *

Any other children? What role, if any, do they play in your child's issues? *

How was your child's birth and first year? Any medical issues? Separations from you? Did you have postpartum depression? Was your child colicky? (If you are consulting me primarily about one child, you only need to answer this for that one child.) *

Any family history on either side of anxiety disorders, depression, bipolar disorder (manic depression), schizophrenia, or other issues? *

Any family history of ADHD, Sensory Processing Disorder, or Autism Spectrum Disorder? *

What was your own childhood like? What about your partner’s if you have one? *

What do you think is causing this issue? *

Are you aware of the peaceful parenting approach? *

Yes. I have read books and/or take classes and/or follow people who talk about it. I know a little bit but it feels very hard to apply. I vaguely know about it. I'm brand new to this approach.

Anything else you think I should know? *

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Parenting coaching intake form

Location

OLYMPIA, WA

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