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Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Book Appointment
Clients portal
Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Menu
Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Appointment
Clients Portal
General Information
Parent/Guardian Name(s):
*
Street Address
*
Apartment, suite, etc
City
State
ZIP / Postal Code
Phone Number(s):
*
Preferred number for contact:
*
Email Address(es):
*
Preferred method of communication (Phone/Email/Text)
*
Family Information
Number of children:
*
Ages of children:
*
Who lives in the home?
*
Are there other caregivers involved in parenting (e.g., co-parent, grandparent, nanny)? (Yes/No)
*
If yes, please describe their role:
*
Primary Concerns
What brings you to parenting therapy/coaching?
*
What specific challenges are you experiencing in your parenting journey?
*
How long have these challenges been present?
*
Have you tried any strategies or sought help in the past? Yes/No
*
If yes, what worked well and what didn’t?
*
What are your goals for parenting therapy/coaching?
*
Parenting Style and Values
How would you describe your parenting style? (Authoritative/Permissive/Authoritarian/Uninvolved/Other)
*
What values are most important to you in raising your child(ren)?
*
What strengths do you bring to your parenting?
*
Parent/Guardian Stress and Well-being
What are your biggest sources of stress as a parent?
*
How do you currently manage stress?
*
What support systems do you have in place (e.g., friends, family, community)?
*
Have you noticed any impact of your stress on your parenting or family relationships? (Yes/No)
*
If yes, please explain:
Child-Specific Concerns (If applicable)
Are there any specific concerns about your child’s behavior or emotions? (Yes/No)
*
If yes, please describe:
Does your child have any diagnoses or is your child receiving support (e.g., IEP, therapy)? (Yes/No)
*
If yes, please provide details:
Logistics and Preferences
Are there specific outcomes you hope to achieve through therapy/coaching?
Is there anything else you’d like us to know?
Submit
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