HParent HMain lobby · Front desk
Form 01 · Front Desk paperwork

Family behavior & assessment intake

This form helps me understand your family's unique dynamic so I can tailor our work together. There are no right or wrong answers — just honest ones.

Private · read only by Cheyenne

Contact

First name *
Last name *
Email *
Phone *

Family overview

Who lives in the home? *
Children's first names and ages *
How many children do you have and what ages? *
Are there any co-parenting arrangements or custody schedules we should know about and be mindful of?
What does a typical day look like in your home? *

Child snapshot

In a few words, how would you describe your child? Make sure to include both the good and the challenges! *
What makes your child special? (What do they do well? What makes them sparkle?) *
What things or activities does your child enjoy the most? (Activities, interests, favorite things)
Does your child have any formal clinical diagnosis? (ADHD, ASD, ODD, DMDD, etc.)
Have you in the past, or are you currently, receiving any mental or behavioral health supports? (therapy, school services, IEP, school aide, etc.)

Behavior concerns

The most important section — take your time here.

What are your top 3 concerns about your child's behavior right now? Rate them on a scale of 1–10 (10 being severe). *
How often do these behaviors happen? *
How intense are these behaviors when they occur? *
When do these behaviors usually occur?
What is your BEST guess at why these behaviors occur? (unpreferred tasks, connection seeking, sensory seeking, difficulty focusing, control, etc.) *
What have you already tried? What has worked? What absolutely does not work? *

Emotional & developmental insight

How does your child typically express emotions? (cries, screams, hits, yells, acts out, runs away, etc.) *
How does your child handle frustration, transitions and being told “no”? *
How do YOU typically handle your difficult emotions?

Parenting & discipline

How would you describe your current parenting approach? *
What discipline strategies do you typically use? *
What is currently going well in your parenting?
What feels hardest about parenting your child right now? What is your biggest challenge? *

Stress & environment

Have there been any recent or significant changes in your family? (move, separation, loss, new baby, school change, medication change, etc.)
Are there ongoing stressors impacting your family right now? (work stress, finances, relationship challenges, etc.)

Goals & vision

What are your goals for parent coaching? *
If coaching was successful, what would be different in your home? *
On a scale of 1 to 10, how ready do you feel to make changes in your parenting? Please explain. (1 = not ready, 10 = fully committed) *

Final reflection

Please explain your willingness and commitment to implementing the strategies and perspectives that you learn in your journey with parent coaching. *
Is there anything else you'd like me to understand about your child or family?

Confidentiality & limits of privacy

Everything you share is kept private. The exceptions: if there is reason to believe you or your child may be at risk of harm to self or others, or in instances of suspected abuse or neglect, Cheyenne is required to act. Parent coaching is not therapy and is not a crisis service.

Confidentiality & limits of privacy *

Signature

I consent to participate in parent coaching services and affirm that the information I have provided is true and accurate to the best of my knowledge.

Signed 10/5/2026

Parent coaching is not therapy and not a crisis service. If you need help right now, call your local crisis line or 911.