Integrative Parenting Group

Parenting Children Who Experienced Trauma

Parent Name

Last Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Which class time do you prefer:

Evening: Mondays 5:00 PM - 6:15 PMMorning: 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?

YesNo

Does your child(ren) have a therapist?

YesN

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?

YesNo

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?

Disabling

Bothersome / Manageable12345DisablingOn a scale of 1 to 5 of concern, how would you rate your child(ren)'s behavior?How do you currently manage the negative behaviors? Has it worked?

What would you like to learn about this group?