Parenting Coach Intake Form

Parent Coach & Classes Intake Form

Bridging Old-School Wisdom with New School-School Strategies for Transformative Parenting
Name

First NameLast Name
Age
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status

SingleMarriedDivorcedWidowed
What time zone are you in?
Preferred contact method.

PhoneTextEmailSnail Mail
Occupation
Are you inquiring about your own child/children?

YesNo
What is your relationships to the child/children your calling about?

MotherGuardianGrandparentFather
How many children?
What are the children's ages?
Are there other adults involved in parenting your children? If so who?
What inspired you to seek parent coaching?
What specific challenges are you currently facing in parenting?
What are your top three goals for this coaching program?
What is your current parenting style?

Authoritative: Balanced and SupportiveAuthoritarian: Strick and ControllingPermissive: Lenient and IndulgentUninvolved: Detached and NeglectfulNot Sure Uncertain Exploring
What are your strengths as a parent?
What areas of parenting do you feel you struggle with the most?
Are there specific behaviors with your child/children that concern you?
How do your child/children typically respond to your parenting strategies?
Have you tried any strategies to help these results: If so, what wee the results?
Do you have children that need special love (special needs, disability)?

YesNo
Do you have a support system in place? e.g. family, fiends, community resources?

YesNo
If yes please how do they support you in your parenting journey?.
Are you currently working with any other professional (e.g. therapist, counselor, teacher, community resource) regarding your child/children.

YesNo
If yes please specify.
What days and times work best for you? Please provide at least 3 options.
What part of the day do you feel most energized?

Early Morning (awake before everyone)Morning (awake with everyone)Afternoon (moving with the crowd)Evening (home with the family)
How do you prefer to meet?

In personPhoneVirtual
Would you like access to any additional resources?

YesNoNot Sure
Is there anything else you would like me to know about your family, your goals or your situation?
What parenting challenges do you struggle with the most? (Select all that apply)

Managing tantrums and emotional outburstsSetting and enforcing boundariesImproving communication with my child(ren)Helping my child(ren) with school and responsibilitiesDealing with sibling conflictsBalancing discipline with nurturingBuilding my child’s confidence and self-esteemOther (please specify) _________
What age group(s) do you need parenting support for? (Select all that apply)

Infants (0-2 years)Toddlers (2-5 years)School-age children (6-12 years)Teenagers (13-18 years)Young adults (18+ years)
What type of parenting class would be most helpful for you?

General parenting skills and techniquesPositive discipline and behavior managementCo-parenting strategies (for divorced/separated parents)Parenting children with special needsParenting through trauma or difficult life situationsStrengthening parent-child communicationOther (please specify) _________
How confident do you feel in your parenting skills?

Very confidentSomewhat confidentNeutralSomewhat unsureVery unsure
How do you currently handle discipline in your home?

Time-outs or other non-punitive consequencesReward systems and positive reinforcementTaking away privilegesSpanking or physical disciplineI struggle with discipline and need guidanceOther (please specify) _________
What format would you prefer for parenting classes?

One-on-one coachingGroup sessionsOnline courses/webinarsIn-person workshopsA combination of these
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.
Parent Coach and Parenting Classes Pricing
prevnext( X )
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 ClassOne-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 Class4-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 Course8-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?

YesNo
If YES is it through your Employer or State of NJ Medicaid ?

EmployerState of NJ Medicaid
How did you find out about our services?

Social MediaYouTube VideoSearch EngineAdsJai Parent Coach DirectoryOther
Would you like to receive product updates, news, and promos?

YesNo
Gender

MaleFemale
Please specify your race/ethnicity. Optional
Should be Empty:

Parent Coach & Classes Intake Form