Parent Coaching Assessment

Parenting Questionnaire

Please select the appropriate response

1. I lose my cool with my child(ren):*

OftenOccasionallyRarelyN/A

2. My child(ren) do not listen:*

OftenOccasionallyRarelyN/A

3. I repeat myself until my child(ren) responds to me:*

OftenOccasionallyRarelyN/A

4. Punishments correct my child's(ren's) behavior:*

OftenOccasionallyRarelyN/A

5. I don't feel effective as a parent:*

OftenOccasionallyRarelyN/A

6. I just don't know what to do when it comes to disciplining my child(ren):*

OftenOccasionallyRarelyN/A

7. I feel that my punishments are too harsh or unfair:*

OftenOccasionallyRarelyN/A

8. It's hard to follow through on punishments:*

OftenOccasionallyRarelyN/A

9. Discipline leads to conflict between me and my child(ren):*

OftenOccasionallyRarelyN/A

10. Discipline leads to conflict between me and my spouse:*

OftenOccasionallyRarelyN/A

11. My child(ren) do not take my verbal threats seriously:*

OftenOccasionallyRarelyN/A

12. Punishments range from severe to doing nothing at all:*

OftenOccasionallyRarelyN/A

13. I don't understand my child's(ren's) misbehavior:*

OftenOccasionallyRarelyN/A

From the drop-down lists below, select the top 5 problem areas you experience with your child(ren)

Younger Children

Older Children

Message

Please fill in your contact information

Full Name*

First NameLast Name

Phone Number*

Format: (000) 000-0000.

E-mail*