Parenting Coach Intake Form

  • Parent Coach & Classes Intake Form

    Bridging Old-School Wisdom with New School-School Strategies for Transformative Parenting
  • Format: (000) 000-0000.
  • Marital Status
  • Preferred contact method.
  • Are you inquiring about your own child/children?
  • What is your relationships to the child/children your calling about?
  • What is your current parenting style?
  • Do you have children that need special love (special needs, disability)?
  • Do you have a support system in place? e.g. family, fiends, community resources?
  • Are you currently working with any other professional (e.g. therapist, counselor, teacher, community resource) regarding your child/children.
  • What part of the day do you feel most energized?
  • How do you prefer to meet?
  • Would you like access to any additional resources?
  • What parenting challenges do you struggle with the most? (Select all that apply)
  • What age group(s) do you need parenting support for? (Select all that apply)
  • What type of parenting class would be most helpful for you?
  • How confident do you feel in your parenting skills?
  • How do you currently handle discipline in your home?
  • What format would you prefer for parenting classes?

  • AGREEMENT/REMINDERS:I understand that all information I entered in this form will be considered strictly confidential.The data gathered from this form will only be used as a basis for the type of coaching I will need.I understand that in order to be successful, it is vital to follow the plan agreed by both the parent coach and the myself. I understand that parent coaching is a collaborative process designed to support me and my parenting goals.

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                  Focused Solution Single Session 60 min

                  Focused coaching on immediate challenges.  Personalized strategies and resources.

                  $125
                    
                  Quick Wins Package: 3 Sessions (60 min/session -3 weeks)

                  $25 Discount when prepaid: Address one or two key parenting challenges. Practical Tools for immediate implication. Email support between sessions.

                  $375
                    
                  Growth and Transformation Package: 6-Sessions: 60 min/session 6 weeks)

                  $75 discount when prepaid: Deeper exploration of parenting dynamic and family challenges.  Learn effective tools to manage behavior and strengthen communication.  Weekly customized action plan . Ongoing email support for guidance between sessions. 

                  $650
                    
                  Ultimate Change Package: 60 min/Session 12 Weeks

                  $200 Save with prepaid payment: Comprehensive coaching for lasting family transformation.  Focus on achieivng long-term parenting goals and establishing new habits. Includes access to exclusive worksheets resources and tools.  Priority email or text support between sessions for ongoing guidance.

                  $1,250
                    
                  Basic Parenting Class

                  One-time 90-minute group session Covers foundational parenting skills (communication, discipline, boundaries) Printable parenting worksheets and resources Q&A session at the end

                  $85
                    
                  Standard Parenting Class

                  4-week course (one class per week, 90 minutes each). Covers positive discipline, emotional regulation, child development, and setting boundaries. Interactive discussions and role-playing exercises. Access to a private online parenting group for support. Completion certificate provided

                  $250
                    
                  Comprehensive Parenting Course

                  8-week course (one class per week, 90 minutes each)Covers all aspects of parenting: behavior . management, effective communication, co-parenting strategies, and emotional intelligence Personalized parenting strategies tailored to each family’s needs. Access to exclusive parenting tools, handouts, and recorded lessons. Direct email support for follow-up questions. Completion certificate provided.

                  $325
                    
                • Do You have Health Insurance?
                • If YES is it through your Employer or State of NJ Medicaid ?
                • How did you find out about our services?
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