Application for the HF Family Program

APPLICATION
For the Healthy Foundations Family Program®

And Deep Dive 10 Week Program
Your name*

First NameLast Name
Name of child (with the biggest challenges)*

First NameLast Name
Child's date of birth*
MM/DD/YYYY
AdoptiveBiologicalKinshipOther
Description of who lives in your home (include ages of your children)*
Brief overview of your behavioral challenges with your child(ren)*
Diagnoses (if you have them)
What you've tried so far*
LyingStealingRunning awayArgues with authorityAggression or violence with siblingsSubstance abuse (drugs or alcohol)Hospitalized in the last yearFeels like I've lost control of our home
Any brief additional comments about the above
For your child with the most challenging behaviors, please answer on a scale from 1-10 by clicking on the number in the circle below.
Level of chaos and behavior problems*

1

2

3

4

5

6

7

8

9

10

1 is Seems normal, 10 is Daily problems
Level of violence/aggression/defiance*

1

2

3

4

5

6

7

8

9

10

1 is Not a problem, 10 is Needing police/safety plan
Controlling behaviors*

1

2

3

4

5

6

7

8

9

10

1 is Minor, 10 is Refusals, argues, won't do as told
School*

1

2

3

4

5

6

7

8

9

10

1 is Manageable, 10 is Daily problems/ suspensions
Anything else you are struggling with that isn't mentioned above
Please list 3 reasons why you feel you need help (or this program) for your family:*
I am committing to make all my scheduled appointments with Dr. AldenI am committed to trying a new approach and doing my best to use the tools I am taught.I am willing to be open and honest about what is happening so that I can be strongly supported through this program
I was referred to youInternet searchSocial mediaInternet adsOther
Please let us know who referred you (and what organization they are with if applicable)*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
City & State*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Should be Empty: