Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Preferred method of communication
*
Birthdate
*
MM
DD
YYYY
Gender
*
Please Select
Male
Female
Prefer not to answer
Race/ethnicity
*
Please select all that apply. This information is collected in confidence as it is sometimes required demographic data for informational purposes when we apply for funding and grants.
Are you of Hispanic, Latino, or of Spanish origin?
*
What is your primary language?
*
Please select.
English
Spanish
French
Mandarin
Arabic
Portuguese
I prefer not to say.
Other (please indicate below)
If you selected "other" primary language, please indicate your primary language here.
Marital Status
*
Are you or have you ever been a member of the U.S. Military?
*
Please select.
Yes
No
How did you hear about us?
*
If you heard about us through a counselor, therapist, OT, church or other, please specify the name below.
Have you or your partner/spouse previously attended a Tried & True class?
*
Attendees
*
Up to two adults living in your home may attend. Please check below to indicate all adults who will be attending.
Name of 2nd adult attending
Email of 2nd adult attending
Phone of 2nd adult attending
(###)
###
####
Birthdate
MM
DD
YYYY
Gender
Please select.
Male
Female
Prefer not to answer
Race/ethnicity
Please select all that apply.
Are you of Hispanic, Latino, or of Spanish origin?
Yes
No
What is your primary language?
English
Spanish
Portuguese
French
Mandarin
Arabic
I prefer not to say.
Other (please indicate below)
If you selected "other" primary language, please indicate your primary language here.
Employment Status
*
Please select.
Full time
Part time
Unemployed - Seeking
Unemployed - Not Seeking
Retired
N/A
Marital Status
Are you or have you ever been a member of the U.S. Military?
Please select.
Yes
No
Child's Name
*
Age
*
Birthdate
*
MM
DD
YYYY
Gender
*
Please Select.
Female
Male
Prefer not to answer
Race/ethnicity
*
Please select all that apply.
Does he/she currently live at home with you the majority of the time?
*
Please select.
Yes
No
Shared custody
Please select which of the following applies to your child.
*
Please select.
Adopted
Biological
Fostering
Participating in Safe Families
If you selected "adopted," please indicate the child's "gotcha day."
MM
DD
YYYY
Will you need childcare for this child?
Child's Name
Age
Birthdate
MM
DD
YYYY
Gender
Please Select.
Female
Male
Prefer not to answer
Race/ethnicity
Please select all that apply.
Does he/she currently live at home with you the majority of the time?
Please select.
Yes
No
Shared custody
Please select which of the following applies to your child.
Please select.
Adopted
Biological
Fostering
Participating in Safe Families
If you selected "adopted," please indicate the child's "gotcha day."
MM
DD
YYYY
Will you need childcare for this child?
Child's Name
Age
Birthdate
MM
DD
YYYY
Gender
Please Select.
Female
Male
Prefer not to answer
Race/ethnicity
Does he/she currently live at home with you the majority of the time?
Please select.
Yes
No
Shared custody
Please select which of the following applies to your child.
Please select.
Adopted
Biological
Fostering
Participating in Safe Families
If you selected "adopted," please indicate the child's "gotcha day."
MM
DD
YYYY
Will you need childcare for this child?
Child's Name
Age
Birthdate
MM
DD
YYYY
Gender
Please select.
Female
Male
Prefer not to answer
Race/ethnicity
Please select all that apply.
Does he/she currently live at home with you the majority of the time?
Please select.
Yes
No
Shared custody
Please select which of the following applies to your child.
Please select.
Adopted
Biological
Fostering
Participating in Safe Families
If you selected "adopted," please indicate the child's "gotcha day."
MM
DD
YYYY
Will you need childcare for this child?
Please explain why you are seeking parent consultation, including a summary of your parenting concern(s).
*
Please share one or two parenting goals.
*
During class, a meal and snacks will be provided for you and any children you have in childcare. Do you or your family have any food allergies we should take into account?
*
(Please list family member's name and allergy if applicable)
Is there any other pertinent information you would like to share with us? Are there any extenuating circumstances we should take into consideration as we think through specific strategies to meet the unique needs of your family? Any complex needs or formal diagnoses that might help us best understand your family and/or special accommodations, plans or situations at school to be mindful of? Please note all of this information will be protected and kept confidential and will not be uncovered or shared during our class time. *
