Family Questionnaire
I suggest that you grab a cuppa and get comfy. This questionnaire is in depth and will take 5-10 minutes. This will give me an insight into your family situation and dynamics, allowing me to tailor the coaching session more appropriately to your specific needs.
Your Name
*
First Name
Last Name
E-mail
*
Phone Number
*
Include ext.
How many children are in your family?
Please Select
1
2
3
4
5
6
7
8
9
10
What is the hardest thing about parenting at the moment?
Kids Behaviour
Marriage/Partner
Parenting Ability
Financial Stress
Other
What are the conflicts in the marriage/partnership?
Not on the same page- parent differently
Financial
One works harder than the other
Not supporting each other
In-laws
Other
How long have you felt this way?
A few days
A few weeks
A few months
A year
Over a year
What is stopping you from parenting the way you want to?
Lack of energy/health
Lack of knowledge
Lack of confidence
Stress
Too busy
Lost joy in parenting
Other
How long have you felt this way?
A few days
A few weeks
A few months
A year
Over a year
Please answer the following questions for each child individually
Child's name
Child's age
Which specific behaviours are you finding challenging?
Bad Attitude - rude, selfish
Distracted and unmotivated
Sibling Rivalry
Aggression
Ungrateful/Entitled
Bullying
Not listening
Selfish
Medical condition
Bad sleeping
Toileting
Eating
Out of control
Other
Tell me three different ways your child feels recharged or refreshed
What are three areas of conflict for this child or for you with this child at the moment?
Please answer the following questions for each child individually
Child's name
Child's age
Which specific behaviours are you finding challenging?
Bad Attitude - rude, selfish
Distracted and unmotivated
Sibling Rivalry
Aggression
Ungrateful/Entitled
Bullying
Not listening
Selfish
Medical condition
Bad sleeping
Toileting
Eating
Out of control
Other
Tell me three different ways your child feels recharged or refreshed
What are three areas of conflict for this child or for you with this child at the moment?
Please answer the following questions for each child individually
Child's name
Child's age
Which specific behaviours are you finding challenging?
Bad Attitude - rude, selfish
Distracted and unmotivated
Sibling Rivalry
Aggression
Ungrateful/Entitled
Bullying
Not listening
Selfish
Medical condition
Bad sleeping
Toileting
Eating
Out of control
Other
Tell me three different ways your child feels recharged or refreshed
What are three areas of conflict for this child or for you with this child at the moment?
Please answer the following questions for each child individually
Child's name
Child's age
Which specific behaviours are you finding challenging?
Bad Attitude - rude, selfish
Distracted and unmotivated
Sibling Rivalry
Aggression
Ungrateful/Entitled
Bullying
Not listening
Selfish
Medical condition
Bad sleeping
Toileting
Eating
Out of control
Other
Tell me three different ways your child feels recharged or refreshed
What are three areas of conflict for this child or for you with this child at the moment?
Please answer the following questions for each child individually
Child's name
Child's age
Which specific behaviours are you finding challenging?
Bad Attitude - rude, selfish
Distracted and unmotivated
Sibling Rivalry
Aggression
Ungrateful/Entitled
Bullying
Not listening
Selfish
Medical condition
Bad sleeping
Toileting
Eating
Out of control
Other
Tell me three different ways your child feels recharged or refreshed
What are three areas of conflict for this child or for you with this child at the moment?
Please answer the following questions for each child individually
Child's name
Child's age
Which specific behaviours are you finding challenging?
Bad Attitude - rude, selfish
Distracted and unmotivated
Sibling Rivalry
Aggression
Ungrateful/Entitled
Bullying
Not listening
Selfish
Medical condition
Bad sleeping
Toileting
Eating
Out of control
Other
Tell me three different ways your child feels recharged or refreshed
What are three areas of conflict for this child or for you with this child at the moment?
The next section is relating to the parents. Please answer for each parent in the household
Parent Name
Where are you placed by birth in your family?
Only
Eldest
Middle
Youngest
Click the one option that most relates to you as a parent:
Introvert (recharged by being by yourself)
Extrovert (recharged by others)
In conflict do you:
Avoid it
Join in
Depends on the scenario
I don’t know
Which personality do you relate to most?
Leader
Cruiser
Perfectionist
Entertainer
The next section is relating to the parents. Please answer for each parent in the household
Parent Name
Where are you placed by birth in your family?
Only
Eldest
Middle
Youngest
Click the one option that most relates to you as a parent:
Introvert (recharged by being by yourself)
Extrovert (recharged by others)
In conflict do you:
Avoid it
Join in
Depends on the scenario
I don’t know
Which personality do you relate to most?
Leader
Cruiser
Perfectionist
Entertainer
Thank you for filling out my questionnaire.
Any further comments?
Please read and accept the terms of the following statements:
*
I understand that Emily is not liable for any actions that you as the client may make after the session and that it will be completely your responsibility how you conduct your actions with your children.
I understand Emily’s qualifications include a bachelor of Education as a trained and qualified teacher but that she is not a counsellor, medical health-worker or psychologist and therefore will not be held liable in these fields.
Submit
Should be Empty: