Neuro-Conscious Parenting Reflection Form

Neuro-Conscious Parenting

Parent Reflection Form
This form helps us to understand your feelings and reactions with more awareness so that we can build a parenting program focused on emotional safety and healthy nervous system development.
Section 1: About You
How many children do you have?

1234 or more
What are the ages of your children?
What feels most difficult for you in parenting right now?
Section 2: Your Feelings & Reactions
In which situations do you feel most upset, angry, or stressed with your child?
When this happens, what feeling comes first?

AngerWorryHelplessnessGuiltStress / OverwhelmSadnessI feel numbOther
Where do you feel this in your body? (For example: tight chest, headache, fast heartbeat, stomach pain)
What do you usually do in that moment?
Section 3: Calmness & Repair
During conflict with your child, how calm do you feel? (Scale 1-10). 1= Not calm at all. 10 = Very calm and steady
After an argument or difficult moment, how long does it take you to feel calm again?

A few minutesA few hoursHalf a dayOne full dayMore than one day
When you make a mistake (like shouting), do you feel comfortable saying sorry and reconnecting?

YesSometimesNot reallyI don't know how
Section 4: Your Childhood & Patterns
Do you notice that sometimes you react like your own parents did?

OftenSometimesRarelyI’m not sure
What behaviors from your childhood do you NOT want to repeat with your children?
Section 5: Growth & Interest
If you could change one thing about how you react to your child, what would it be?
Would you like to join a small group program to learn how to stay calm and build a stronger emotional connection with your child?

YesMaybe (I want more details)Not now
Full Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Country CodeArea CodePhone Number
Email
example@example.com
APPOINTMENT: Please Input Pre-Decided Meeting Date and Time (Will have been decided telephonically before form is sent)
Signature
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I agree to by clicking here, ACCEPT the terms, conditions and disclaimers of working with Samia Athar and duly submit this form to her in preparation of my scheduled session by signing my name below.
Waiver : Please read carefully

LIABILITY: I hereby release Samia Athar (RTT Therapist) from any liability or claims that could be made against her concerning my mental and/or physical well-being during the work that has been outlined and agreed upon now and in the future by filling out this form.

SCOPE OF PRACTICE: I understand that Samia Athar is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnosis should not be considered a replacement for the advice and/or services of a Psychiatrist, Psychologist, Psychotherapist or Doctor.

PARTICIPATION: I give Samia Athar full permission to use Rapid Transformational Therapy and CBT knowing that by participating fully in the process, I play an important role in my overall success.

GUARANTEE: I understand that although Rapid Transformational Therapy and CBT has an incredibly high success rate, Samia Athar cannot and does not guarantee results since my own personal success depends on many factors that Samia Athar has no control over, including my willingness and desire to affect the changes inside myself.

PRIVACY: Samia Athar will maintain confidentiality of my session. This session does not replace medical diagnosis or treatment.
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Neuro-Conscious Parenting

Section 1: About You

Section 2: Your Feelings & Reactions

Section 3: Calmness & Repair

Section 4: Your Childhood & Patterns

Section 5: Growth & Interest