Free Consultation Form

Intake Questionnaire for LA Parent Collective
1 Full Name
2 Address
3. Phone Number
4 Email Address
example@example.com
Preferred Method of Contact

Phone CallTextEmail
What type of consultation are you seeking?

General ParentingCo-ParentingIEP/Special Education
Family Information
Number of Children and Ages:
Are there any other caregivers involved? (e.g.,step parents, grandparents)
Current Custody Arrangement (if applicable)

Joint CustodySole CustodyOther
Consultation-Specific Information
For General Parenting Consultations
What are the main areas you would like support in?(Choose all that apply)

Discipline and BoundariesCommunication with ChildrenBuilding Self EsteemManaging Screen TimeAcademic SupportBehaviorIntroducing new additions to the familyOther
Are there specific challenges you're facing with your child or children?
What are your goals for this consultation?
For Co-Parenting Consultations
Describe the current co-parenting arrangement:
Are there any court orders in place or pending?
Date of Most Recent/Upcoming Court Appearance if applicable

MonthDayYear
Date
What are the primary challenges in your co-parenting situation?

CommunicationConflict ResolutionSchedulingNew RelationshipsFinancesOther
What specific goals do you have for co-parenting?
2 Are there specific challenges youre facing with your child or children
3 What are your goals for this consultation
For IEP/Special Education Consultations

1. Does your child currently have an IEP or 504 Plan? 2. What school does your child attend?
For IEP/Special Education Consultations
1 Does your child currently have an IEP or 504 Plan?
2 What school does your child attend? Please include City/County and State
What are the primary areas of concern related to your childs education, IEP or 504 Plan?

Academic PerformanceBehavior in schoolCommunication with school staffAccommodations and ModificationsTransition PlanningOther
Do you have an upcoming IEP/Conference meeting? (if Yes, please specify the date)
What are your goals for this consultation
Additional Information
How did you hear about LA Parent Collective?
Preferred days and times for consultation. Available via Zoom and by telephone.
Should be Empty:

Intake Questionnaire for LA Parent Collective

Family Information

Consultation-Specific Information

For General Parenting Consultations

For Co-Parenting Consultations

For IEP/Special Education Consultations

Additional Information