Parent Pal Contact Form

Parent Pal Contact Form
If you have any questions or need assistance please contact us at (301) 781-8189 or emailus@parent-pal.com
Before your first Parent Pal session, please complete this brief Contact Form. The Form helps us customize your session and ensure we assign the right Parent Pal to your family. You can also complete the form online, download it, and send it to emailus@parent-pal.com
Are there any active court orders that affect child's interaction with either of his/her/their parents or interaction between parents? (e.g., an Order of Protection naming the child or either of the parents, court-ordered supervised visits, etc.)? If so, you are ineligible for advice and/or coaching at this time.
How would you like to meet with your Parent Pal?

ZoomTelephoneFacebook MessengerIOS Facetime
Name of Parent(s), Grandparent(s), or Caregiver(s)*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone or Cell Number*

Area CodePhone Number
Email*
example@example.com
Child/Children/Teen's relationship to you:*

Mother(s) and/or Father(s)Step Parent(s)Grandparent(s)Foster Parent(s)Adopted Parent(s)Guardian(s)Other
Reason(s) for seeking Parent Pal Advice and Coaching*
Does the child/children/teen(s) have a history of problematic behaviors (e.g., oppositional defiance, backtalk, peer pressure, etc.)? If so, please explain.
Type of service requested

Parent Pal 1-Hour SessionParent Pal 45-Minute SessionParent Pal 30-Minute SessionParent Pal Monthly Coaching Session (4 Monthly Sessions)
By submitting this form, you acknowledge and accept that any services provided do not constitute or replace medical or therapeutic intervention. Parent Pal coaches and advises for educational purposes and does not assess, diagnose, or treat any behavioral and/or mental health conditions. As a division of a Limited Liability Company (LLC), we do not assume liability for any conditions resulting in injury, harm, and/or death.

All consultations with Parent Pals are private and confidential. Parent Pal does not record or transcribe sessions but may take notes for internal use. Parent Pal does not accept private insurance.
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