Application for the HF Family Program

APPLICATION
For the Healthy Foundations Family Program®

This application helps me to understand your family. Please answer fully as you can.
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

Other
Description of who lives in your home (include ages of your children)
What behaviors are you seeing, and how often?
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)
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
What is prompting you to reach out now?
Please list 3 reasons why you feel you need help (or this program) for your family:
Please mark each of these signaling agreement to work with Dr. Alden and to participate fully in this program. Your commitment is needed for the changes you want in your home: Are you willing to:
How did you hear about us?

Other
Please let us know who referred you (and what organization they are with if applicable)
Your 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: