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Parent Coaching & Mentoring Program Inquiry
4 minutes to complete
10
Questions
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HIPAA
Compliance
1
Today's Date
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Date
Year
Month
Day
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2
Child(ren)'s Goals & Needs
Please rate the needs and goals you have in regards to your child(ren)'s development (Top Priority), at a later time (Want to Address at in the Future), or not at all (Not a Concern).
Top Priority
Want to Address in the Future
Not a Concern
Learn about new approaches to support my child(ren) development
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Gain strategies & support to help my child with a specific challenge
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Support with managing my child(ren)'s difficult behaviors
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Help my child(ren) manage their stress & anxiety
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Support with emotional regulation (my child(ren) or me
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Learn how to support my child's self-regulation skills
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Help my child(ren) to sleep better
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Help my child with social skills
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Support my child's development of executive functioning skills
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Learn about new approaches to support my child(ren) development
Gain strategies & support to help my child with a specific challenge
Support with managing my child(ren)'s difficult behaviors
Help my child(ren) manage their stress & anxiety
Support with emotional regulation (my child(ren) or me
Learn how to support my child's self-regulation skills
Help my child(ren) to sleep better
Help my child with social skills
Support my child's development of executive functioning skills
Top Priority
Row 0, Column 0
Want to Address in the Future
Row 0, Column 1
Not a Concern
Row 0, Column 2
Top Priority
Row 1, Column 0
Want to Address in the Future
Row 1, Column 1
Not a Concern
Row 1, Column 2
Top Priority
Row 2, Column 0
Want to Address in the Future
Row 2, Column 1
Not a Concern
Row 2, Column 2
Top Priority
Row 3, Column 0
Want to Address in the Future
Row 3, Column 1
Not a Concern
Row 3, Column 2
Top Priority
Row 4, Column 0
Want to Address in the Future
Row 4, Column 1
Not a Concern
Row 4, Column 2
Top Priority
Row 5, Column 0
Want to Address in the Future
Row 5, Column 1
Not a Concern
Row 5, Column 2
Top Priority
Row 6, Column 0
Want to Address in the Future
Row 6, Column 1
Not a Concern
Row 6, Column 2
Top Priority
Row 7, Column 0
Want to Address in the Future
Row 7, Column 1
Not a Concern
Row 7, Column 2
Top Priority
Row 8, Column 0
Want to Address in the Future
Row 8, Column 1
Not a Concern
Row 8, Column 2
1
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3
Parent Goals & Needs
Please indicate which needs and goals you want to address first (Top Priority), at a later time (Want to Address at in the Future), or not at all (Not a Concern).
Top Priority
Want to Address in the Future
Not a Concern
Manage my stress
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Decrease feeling of overwhelm
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Change my reactions when triggered
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Decrease my feelings of frustration
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Be more calm & patient
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Support setting firm boundaries & rules
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Find more balance between meeting my child(ren)'s needs & my own.
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Manage my stress
Decrease feeling of overwhelm
Change my reactions when triggered
Decrease my feelings of frustration
Be more calm & patient
Support setting firm boundaries & rules
Find more balance between meeting my child(ren)'s needs & my own.
Top Priority
Row 0, Column 0
Want to Address in the Future
Row 0, Column 1
Not a Concern
Row 0, Column 2
Top Priority
Row 1, Column 0
Want to Address in the Future
Row 1, Column 1
Not a Concern
Row 1, Column 2
Top Priority
Row 2, Column 0
Want to Address in the Future
Row 2, Column 1
Not a Concern
Row 2, Column 2
Top Priority
Row 3, Column 0
Want to Address in the Future
Row 3, Column 1
Not a Concern
Row 3, Column 2
Top Priority
Row 4, Column 0
Want to Address in the Future
Row 4, Column 1
Not a Concern
Row 4, Column 2
Top Priority
Row 5, Column 0
Want to Address in the Future
Row 5, Column 1
Not a Concern
Row 5, Column 2
Top Priority
Row 6, Column 0
Want to Address in the Future
Row 6, Column 1
Not a Concern
Row 6, Column 2
1
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4
Please share additional details of the problem(s) or challenge(s) you seek support for in the box below.
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5
Have you tried any other approaches, services, or support to help with your current problem(s) or challenge(s), if so please list below.
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6
Ages of your child(ren)
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7
My child or children have the following diagnosis.
anxiety
attention deficit disorder (ADD/ADHD)
autism
coordination delays
depression
dyspraxia or dysgraphia
dyslexia
learning disability or challenges
obsessive compulsive disorder (OCD)
language and communication delays (mild)
language and communication delays (moderate - severe)
twice-exceptional
concerns with development (no diagnosis)
no concerns or delays
Other
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8
Your Name
First Name
Last Name
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9
Email
example@example.com
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10
If there is anything else you would like to add about your situation, challenges, or goals, please share below.
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