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Parent Questionnaire
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Email
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Your email
Parent Name(s)
*
Your answer
Phone number
*
Your answer
Occupation(s)
Your answer
Child Name and Age
Your answer
Child Name and Age
Your answer
Child Name and Age
Your answer
Child Name and Age
Your answer
List main concerns in order of importance
Your answer
List main goals in order of importance
Your answer
Does your family have a regular weekday routine?
Yes
No
Sometimes
Clear selection
Please briefly explain your weekday routine as a family
Your answer
Does your family have a regular bedtime routine?
Yes
No
Sometimes
Clear selection
Please briefly explain your bedtime routine with your child(ren).
Your answer
Do you experience any bedtime/night time struggles with your child? If so please explain.
Your answer
Does your family have a regular weekend routine?
Yes
No
Sometimes
Clear selection
Please briefly explain what weekends look like for your family.
Your answer
Who is the primary caregiver for your child(ren)?
Your answer
If married, do you feel you and your spouse are on the same page in terms of raising your child(ren)?
Your answer
If parenting time (custody) is shared, do you feel that you are on the same page as the other parent in terms of raising your child(ren)?
Your answer
Are there any other caregivers involved in raising/caring for your child(ren)?
Your answer
Are there any concerns other caregivers, teachers, or relatives have brought to your attention about your child(ren)?
Your answer
Has your child been diagnosed with any medical condition or learning challenge such as dyslexia, torticollis, acid reflux, ADHD, etc.?
Your answer
What parenting strategies have you tried so far?
Your answer
What parenting strategies have worked well?
Your answer
What hasn't worked so well, and why?
Your answer
Do you feel your child has a balanced diet?
Yes
No
Clear selection
The session for this group will be recorded and distributed to other members within the group as needed. If you consent to this please type your first and last name below.
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Your answer
What is shared within the group is to remain confidential. Please do not share outside of the group.
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I agree
Are you aware this group is hosted live, via Zoom at US Mountain Standard Time?
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Option 1
As a part of this beta testing group, I may ask for your feedback and input to help me improve the process for future groups. Are you willing to complete 2-3 short surveys throughout your 6 week program?
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Yes
No
Would you like to stay connected to parenting tips, hot topics, and upcoming events by joining our email list? If so, please enter your email address below!
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A copy of your responses will be emailed to the address you provided.
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