FamilyKind NYS Certified Parent Education Class/IPE Intake Form

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Your confidential answers are for FamilyKind purposes only so that we may contact you and provide you with the most appropriate service.

First Name *

Last Name *

Phone Number *

Alternate Phone Number

Email Address *

Street Address and Apartment Number *

State *

Please list country if outside of the the United States

Zip Code *

If from New York, in which Borough/County do you live? *

Bronx

Brooklyn/Kings

Manhattan/New York

Nassau

Queens

Staten Island/Richmond

Suffolk

Westchester

Other

I do not live in New York

Other:

Date of Birth *

YYYY

What service are you requesting? *

Individualized Parenting Education (IPE): Parenting educators meet with single or co-parents to identify, apply and strengthen parenting and family skills.

NYS Certified Parent Education Class: For divorcing and separating parents, 4.5-hour class to empower parents to keep children “out of the middle” of parental conflicts and teach them healthy communication skills. Certificate provided.

How did you hear about FamilyKind? *

Attorney

Court/Judge

Agency

Case Manager/Mental Health Professional

Internet search

FamilyKind website

Friend

Other:

Name of person or agency who referred you:

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