Private Family Intake Form
This form is for families to fill out on their own behalf after having a free 30 minute consultation with Angie.  Completing this form will put your family on our waitlist.  When a coach becomes available, we will email and/or text you to see if you are still interested in our services.  You are not bound to any service by completing this form.

Please review the two following documents: Memorandum of Understanding and Services and Fees. If you do choose to begin direct coaching services, submitting this form represents your agreement to the terms of the Memorandum of Understanding and Services and Fees. Please contact Angie at timeoutbehaviorcoaching@gmail.com if you have further questions.

Thank you for your interest in our services.  It will be a privilege to work with you!
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Email *
First Name *
Last Name *
Phone number *
Street Address *
City *
State *
Zip Code *
Second Caregiver First Name
Second Caregiver Last Name
Email of secondary caregiver 
Phone of secondary caregiver 
Please describe your living situation (biological family, step-family, etc). *
Names and ages of any other child(ren) in the family *
Please indicate concerns the family previously or currently may be experiencing.  If something is not on this list, feel free to add more information below. *
Abuse
Addiction
ADHD
Aggression/Anger
Anxiety
Autism
Depression
Grief/Loss
Neglect
Truancy
Other
Not Applicable/Unknown
Caregiver #1
Caregiver #2
Child #1
Child #2
Child #3
Please elaborate on the above and email us any documentation that would support us in our work. *
Please summarize the top three concerns and top three goals you have for your family and any additional information you wish us to know. *
Your preferred availability: *
Morning
Afternoon
Evening
Unknown at this time
Monday
Tuesday
Wednesday
Thursday
Friday
Weekends
Next
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