Parenting: Course Registration Form

Private Parenting Course Registration

To be completed by each participant . The Coach & Therapies Centre will hold the information you have provided for the purpose of pastoral care, administration and to keep you informed of their other services and activities. Please note that in the event you are working with one of our named partners or associates- this form will be shared with the persons with whom will be carrying out the direct work with you. With exception to this- your information will not be shared. IF MAKING A REFERRAL - COMPLETE LAST SECTION ALSO
Course Selection

Fear Less Triple PPathways Triple PFamily Transitions Triple PParenting ApartStandard Triple P (0-12yrs)Primary Care Triple PFreedom
Preference

Online - School HoursOnline Evening / WeekendsIn Person - (Chiswick Site)
- Full Name*
  
  First NameLast Name
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip CodeCountry
- Local Council / Borough
- E-mail*
  Parent 1
- Contact Number*
  
  Area CodePhone Number
- Birthdate
  
  MonthDayYear
  Date
- Child(ren)s Details*
- Are any of these current to you / your family? (either yourself or your child(ren)
  
  Mental IllnessChild Protection PlanChild In Need PlanLong- Term Health IssueEHCP PlanOther
- Which best describes the household where the child lives?
  
  Original Family (Biological or adopted parents)Original family, (living with extended family`)Single parent familySingle parent family, (living with grandparents)Step familyFoster familyOther
- How many people including the child live in the household
- Monitoring:
- Total annual household income
  
  £20,000 or less£20,001 - £30,000£30,001 - £40,000£40,001 - £50,000£50,001 - £60,000£60,001 - £70,000£70,001 - £80,000£80,000 +
- Do you require any support with speaking or writing in English?
  
  NoYesOther
- Do you receive any additional support for any of your children?
  
  YesNoAwaiting ReferralAwaiting AssessmentOther
- What would you like to achieve from attending a course with us?
- Please Share your Ethnicity as you identify
  i.e. White British, Black Caribbean, Romany Traveller, Mixed Race
- Course Pathway
  
  Self ReferralGPCourt OrderSocial Worker/ CafcassCharity/ CICChildren's CentreHealth VisitorCAMHSOther
- I give permission to be contacted at a later stage to evaluate how effective the parenting support is still proving?
  
  YesNo
- I would like to be contacted about future courses, seminars, webinars, events etc?
  
  YesNo

Private Parenting Course Registration

In-House Admin Use Only