Integrative Parenting Group
Parenting Children Who Experienced Trauma
Parent Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Child's Insurance Information
Group
Insurance Company Name
Group #
Which class time do you prefer:
Evening: Mondays 5:00 PM - 6:15 PM
Morning: Tuesdays 9:00 AM - 10:15 AM
What is/are the age(s) and grade level(s) of your child(ren)?
Is your child(ren) currently in counseling?
Yes
No
Does your child(ren) have a therapist?
Yes
No
If yes, who?
What is/are your child(ren)'s mental health diagnosis?
What is/are your child(ren)'s strengths? What do they like/what are they good at?
Has the child(ren) and/or family experienced trauma?
Yes
No
How has this impacted your child? (If multiple children, list trauma for each child.)
Concerning behaviors you would like help with:
What are your child(ren)'s current negative behaviors? (If multiple children, give negative behaviors of each child)
On a scale of 1 to 5 of concern, how would you rate your child(ren)'s behavior?
Bothersome / Manageable
1
2
3
4
Disabling
5
1 is Bothersome / Manageable, 5 is Disabling
How do you currently manage the negative behaviors? Has it worked?
What would you like to learn about this group?
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