BeH2O Intake Form
Cohort starting June 2, 2026 .
Today's Date
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Month
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Day
Year
Date
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Employment Status / Position Description
*
Date of Birth
*
/
Month
/
Day
Year
Date
Current Marital Status
*
Current Partner's Name
*
Co-Parent's Name
*
Lenth of Separation/Divorce
*
Child(ren)'s First Name(s) & DOB:
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Please describe your current parenting time schedule
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Please provide a brief relationship history (length of relationship, cause of separation, etc.)
*
What is currently occurring between you and your co-parent that prompted your referral/interest in the program?
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How do you think your co-parent is contributing to these issues?
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How are you contributing to these issues?
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From your perspective, what are the most significant barriers to creating civil, productive and child-focused interaction with your co-parent?
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What do you think is in your child(ren)'s best interest in relation to your co-parenting relationship?
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Please define your goals for the program in relation to your co-parenting relationship. What would you like to develop/gain at the completion of the program?
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Do you have personal goals for the program? Are there things that you would personally like to work on or improve upon?
*
How would you like to make payments?
Please Select
Pay in full $1,600 (waive $150 intake fee)
Pay weekly ($1,750 in total)
Submit
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