Intake Form & Agreement
Welcome! Our work together is more effective and efficient if you can share some information about yourself before we get started. I encourage you to be open in order to get the most out of our time together.
Name
*
First Name
Last Name
Email
*
example@example.com
Name of Spouse/Partner
First Name
Last Name
Email
example@example.com
Names & Ages of Children:
First Name
Last Name
Age of Child
Grade
First Name
Last Name
Age of Child
Grade
First Name
Last Name
Age of Child
Grade
First Name
Last Name
Age of Child
Grade
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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What do you hope to achieve from our work together? What are your goals?
*
What are the specific behaviors of your children that frustrate you the most?
*
What parenting techniques are you using currently? Are they effective?
*
Describe your relationship with each of your children.
*
What factors might get in the way as you begin to use your new tools? (i.e.lack of sleep, disapproving role models, etc.)
*
Please let me know about any sleep issues. Approximately how many hoursof sleep does each child get per night?
*
Do the children have any relevant diagnoses? (i.e. ADD, Learning Issues)
*
How did you hear about my services?
*
What fun things/activities does your family enjoy doing together?
*
What do you and your spouse do for work? What are your hobbies?
*
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Our Agreement
I’m so glad to be working with you! In order to bring our ‘best selves’ to the coaching relationship and build trust, it is important that we share the same understanding about how we will work together. Please read, sign and return this form to wendypetricoff@gmail.com.
Our Contract.
Private coaching packages and will be paid prior to the first session via Paypal,
venmo or other agreed upon method.
Private coaching session times/dates will be agreed-upon both parties. Please
call Wendy Petricoff at 704-905-8659 at the time of your session or connect
online via zoom.
Private sessions are one hour long and can take place online or via phone.
Package and Course Fees are non-refundable. If you are unable to use your
sessions for any reason, you may place them on a 3-month hold. Session credits will not be carried out further than 3 months.
Should you need to cancel or reschedule a session please provide advance notice.
Confidentiality of our communication will be maintained to the extent defined by
the laws of the states in which we reside.
I understand that Charlotte Parenting Solutions does not purport to offer mental
health care, psychoanalysis or behavioral therapy. I further understand that I am always free to reject any advice, suggestions or requests made by Charlotte
Parenting Solutions at any time. Coaching results are not guaranteed. Client enters into coaching with the understanding that they are responsible for creating their own results
I, the client have read and agree with the above:
Client Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
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Should be Empty: