Application for the HF Family Program

APPLICATION
For the Healthy Foundations Family Program
(coaching or in-home options)

If you are not sure, schedule a FREE 15-minute phone call with Dr. Alden.
Your name*

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

First NameLast Name
Child's date of birth*
MM/DD/YYYY
Which best describes your family*

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*
Issues you've had or are currently having with your child(ren) - (click all that apply)*

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:*
Which best describes your situation:*

I would like the 90-day in-home program (Idaho Medicaid only)I would like the 12-week online coaching programOther
If you are chosen to do this program, we ask that you commit to the following:
- Being open and willing to try new approaches even if they don't always make sense.
- To work with your parent coach through the challenges you face even when you don't feel like you have the energy to continue.
- Being willing to stay committed for the entire program for the best possible outcome for your family.
Does your child have Idaho Medicaid?*

YesNo
How did you hear about us?*

I was referred to youInternet searchSocial mediaOther
Please let us know who referred you (and what organization they are with if applicable)*
How would you prefer to be contacted?*

PhoneEmailTextDoesn't matterOther
Phone Number
Please enter a valid phone number.
City & state*

Street Address

Street Address Line 2

CityState

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