S.O.S. Kids! Introductory Parent Survey

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Dear Parent,

Thank you for reaching out about an S.O.S. (Sassy, Stubborn, Strong-willed Or Spirited!) session for your amazing kiddo. I really look forward to helping you see, understand, cultivate & guide the immense power and potential that's surging inside them.

Your feedback in this survey will allow me to get a feel for how your child operates day by day, and what issues feel like the biggest challenges you may be experiencing. Please feel free to add any further info that you think would be relevant for me to know in the spaces provided.

In the meantime, I'll begin to analyze the energetic blueprint (i.e. their Human Design chart), which makes your child a powerful force to be reckoned with! Please note: *Your child's birthdate, time and city are critical pieces of data that I need in order to compile their Human Design chart. As such, their birth details, as accurately as you're able to share, are required. I will compile their chart, analyze the energetic traits that make up their blueprint, and provide you with my findings during our scheduled 1:1 session.

If you have any questions or concerns, or have not yet scheduled a 1:1 session, please reach me anytime by email at ellsworthjaneen@gmail.com, or by phone/text at (412) 867-0487, and I will respond asap!

For more information about Human Design, please visit https://janeenellsworth.com/work-with-me/, or follow me on IG at @janeenjustlikeitsounds and Facebook at @healwtihHD. Thank you!

Email *

What's your name, and how would you like me to address you?

You can keep your child's name private, but let me know here if they have a preferred gender pronoun:

What is your child's date of birth? *

YYYY

What time was your child born (as accurately to the minute as you're able to provide)? *

Time

What city, state, and country was your child born in? *

Choose the statement below that best describes your child's sleep pattern:
*

My child is a good sleeper. They usually fall asleep easily and stay asleep through the night.

My child is an okay sleeper. It takes them a while to settle in at night but once they're asleep, they usually stay asleep.

Sleep is difficult for my child. They have a hard time dozing off, stay up late often, and have frequent wakeups through the night.

Other:

Agree or disagree: My child is a picky eater.
*

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Agree or disagree: My child has a vivid imagination & enjoys engaging in creative play and/or artistic expression.
*

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Would you consider your child to be strong willed?
*

Yes, my child is extremely strong willed about most everything!

No, my child is usually fairly easygoing.

Somewhat. My child shows conviction but only for certain things.

Choose the statement below that best describes your child's emotions:
*

My child is extremely emotional. They experience big up-swings and down-swings when it comes to their feelings.

My child is fairly even-keeled when it comes to their emotions. They don't show big swings or get particularly emotional about things.

My child is not emotional at all. They hardly ever show their feelings.

Agree or disagree: My child is stubborn.
*

Strongly disagree - they are never stubborn

Disagree - they are rarely stubborn

Agree Somewhat - they are occasionally stubborn, as a 'normal' child ought to be

Agree - they are often stubborn

Strongly agree - they are almost always very stubborn

Choose the statement below that best describes your child's physical energy:
*

My kid is a mover! They're constantly fidgeting, dancing, hopping or bouncing. They need lots of physical activity.

My child is moderately physically energetic. They enjoy physical activity but they're not particularly or constantly active.

My child is physically low-key. They're not super interested in physically active play or engaging in sports. They'd rather sit and read a book or chill with some TV.

Other:

Agree or Disagree: My child is a worrier.
*

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Would you consider your child to be a 'chatterbox'? Choose the option below that most closely matches:
*

Not at all. My child is generally quiet and doesn't like to speak up.

Not especially. They talk a moderate amount.

Absolutely! My kiddo never shuts up!

Other:

How 'open-minded' would you say your child is with regard to hearing others' ideas and trying different things (new foods, activities, etc.)?
*

Not open-minded at all; won't accept others' ideas or try new things

Somewhat open-minded; willing to listen to ideas and sometimes try new things

Extremely open-minded; usually willing to hear new ideas and try new things

How frequently does it appear that your child wants to take the lead in activities?
*

Always

Sometimes

Never

Which statement most closely describes your child's social interactions?
*

My child is a true extrovert, loves being around other kids and enjoys having lots of play dates/hangouts.

My child is both introverted and extroverted; they have a few close pals and occasionally meet up with friends outside of school to play or hang out.

My child gets overwhelmed around other kids and it seems hard for him/her/them to make friends.

My child is shy and a true introvert but has one or two close friends.

My child is a total loner, completely uninterested in bonding with other children.

Agree or Disagree: My child is willing to be helpful at home.
*

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

True or False: I sometimes worry that my child may have anger issues.
*

True

False

True or False: I sometimes wonder if my child is a narcissist.
*

True

False

Does your child participate in extracurricular activities? If so, how many?
*

Yes, my child currently participates in 3 or more extracurricular activities weekly.

Yes, my child currently participates in 1-2 extracurricular activities weekly.

No, my child does not currently participate in any extracurricular activities but they would like to.

No, my child does not currently participate in any extracurricular activities because they do not want to.

Other:

Choose the statement that most accurately describes your child's relationship with fear:

My child is frequently very fearful, even when it would be considered 'unreasonable' or irrational to be afraid.

My child shows a 'healthy' or 'normal' amount of fear at appropriate times.

My child is fearless and will try anything without considering consequences.

Other:

Clear selection

What kind of methods/supports is your child currently receiving to help with their behavior or state of mind?

Mental health counseling/therapy

IEP at school

Behavior specialist at home or at school

Private parenting coach

Other:

Are there any other areas of concern that you have with respect to your child, or would you like to share any final comments about your kiddo's needs, tendencies or habits?
*

Thank you for participating in this survey!
*

Send me a copy of my responses.

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