Consultation Intake

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
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Mobile Phone Number* This field is required.We'll call or text if you are running late to our scheduled time.
Please enter a valid phone number.
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What is your child's age?* This field is required.
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How would you rate the severity of the challenges you are currently facing with your child?* This field is required.Scale: 1 = Not Very Severe, 10 = Extremely Severe
Please Select
Please Select
1 = Not Very Severe
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10 = Extremely Severe
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Which of the following statements best describes the current situation you are facing with your child?* This field is required.
We're experiencing this scale of challenges for the first time and trying to avoid escalation
We've had challenges for a while, but haven't taken major steps to resolve them
We've tried a lot of options and are still struggling
We are currently in a crisis (you'll be able to explain later)
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Briefly describe the options you have explored in the past.* This field is required.
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Describe the struggles your child is experiencing and how they are impacting you (as the parent) and other family members in the home (i.e. siblings). * This field is required.
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Ok
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If there is one thing you'd like to improve in the situation with your child, what would it be and why?* This field is required.
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10
How serious are you about finding an achievable solution to the challenges you are facing with your child?* This field is required.Scale: 1 = I'm not very serious right now, 10 = I'll do whatever it takes to help my child
Please Select
Please Select
1 = I'm not very serious right now
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10 = I'll do whatever it takes to help my child
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Is there anything else I should know that will help me prepare for our call? (Optional)Please let me know, briefly, about challenges with other adolescents and teens in the house. It's also helpful for me to know about conflicts with co-parents that might implact the plan we'll work on together.
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This free consultation will empower you in your path toward improving the challenging situation with your child. Are you willing and able to invest in continued training/coaching IF we both agree additional conversations are exactly what you need to achieve the goals listed above and you are a good fit with our model?* This field is required.
I am willing and able to invest if this is what I need
If it makes sense, I will find a way to invest to achieve my parenting goals
Even if I want to, I might not be able to pursue continued services
I am not currently interested in paid services
13
I agree to show up at the scheduled time and understand I will not be able to reschedule if I miss the consultation.* This field is required.
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