Parenting From The Heart Coaching Questionnaire

(Please fill out only after speaking with Linda or Ty concerning your situation)

Please offer three different dates and times you are available for parent coaching.

We will confirm an available date as soon as possible. Our hourly rate is $275 an hour and always includes both Linda and Ty.

Name *

First

Last

Email *

Phone: *

Your available dates for coaching session: *

Example: January 10, 5PM

Dates second choice:

Dates third choice:

1. What are the names, sex and ages (month and year) of your children? *

2. What grade is each child in school?

3. What are your current occupations and how many hours does each parent generally work a week?

4. What self-help skills do each of your children do for themselves? i.e. make their own bed, get themselves up in the morning.

5. How many hours a day and or per week are you allowing for each technology in your home? (Include all forms i.e. TV, laptop, iPad, gaming machines, movies, etc...)

6. What chores/responsibilities do each of your children have around the house? i.e. take out the trash, feed a pet, clean dishes.

7. Who do your children live with?

8. What our your children's bedtime routines starting from dinner to lights out in bed? What time do they get up in the morning?

9. What is your parenting style? What is your partner's parenting style? How do you currently handle conflicts and challenges with your children? (copy)

10. Have there been any "changes" in your home recently including health challenges?

11. What professional assistance have you tried if any, including medications?

12. How were you parented in your family?

13. What are your main concerns and challenges with each of your children?