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4 Weeks To Be A Better Parent Intake Form

 This short intake helps me understand your family, your child, and what feels hardest right now, before we meet.

There are no right or wrong answers. This isn’t a test, and it’s not about labeling you or your child. It’s simply a way to slow things down, notice patterns, and make sure our time together is focused on what matters most to you.

 

 

Your responses will help me:

  • See your current parenting landscape

  • Understand the moments that create the most stress

  • Spot patterns that may be repeating without you realizing it

  • Support you with clarity instead of guesswork

Take your time. Answer honestly. Share only what feels comfortable.

This form allows us to spend less time collecting background and more time helping tomorrow feel different.

 

Click the button below to start.

 

Start

Question 1 of 13

Child's age or ages

Question 2 of 13

Which moments feel hardest right now?

(Select all that apply)
A

Morning routines

B

Transitions or waiting

C

Emotional meltdowns

D

Not listening

E

Sibling conflict

F

Bedtime

G

School or daycare stress

H

Other

Question 3 of 13

When your child is upset, which response sounds most like you?

(Select all that apply)
A

I try to calm them quickly

B

I explain or reason

C

I get quiet or withdraw

D

I get frustrated or overwhelmed

E

I try to stay strong and not show emotion

F

I’m not sure yet

Question 4 of 13

Growing up, how were emotions handled in your home?

A

Talked through openly

B

Minimized or rushed

C

Ignored unless serious

D

Discouraged or punished

E

I’m still figuring this out

Question 5 of 13

What’s something you wish you understood better about your child right now?

Question 6 of 13

If you could change one thing about how you’ve been showing up as a parent lately, what would it be?

Question 7 of 13

What emotion do you tend to hide from your child because you don’t want them to worry or think less of you?

A

Sadness

B

Fear

C

Frustration

D

Uncertainty

E

Exhaustion

F

Other

Question 8 of 13

What’s something you hope your child never has to experience, but you quietly worry they might?

Question 9 of 13

If PPP works well for you, what would feel different in your home 30 days from now?

Question 10 of 13

 

(On a scale from 1-10)

How at peace do you feel at night about your parenting decisions?

A

1–3 - (I often replay parenting moments, second-guess myself, or go to bed feeling like I messed something up.)

B

4–6 - (Some nights feel okay, but I still replay certain moments or wonder if I handled things the right way.)

C

7–8 - (Most nights I feel fairly settled, even if I know I’m still learning.)

D

9–10 - (I usually go to bed feeling confident and at peace with how I showed up as a parent.)

Question 11 of 13

 

(On a scale from 1-10)

How confident do you feel knowing what to say or do in the moment with your child?

A

1–3 - (I often freeze, react emotionally, or guess because I’m not sure what to do.)

B

4–6 - (I have some instincts, but in stressful moments I still feel unsure or inconsistent.)

C

7–8 - (Most of the time I feel grounded and know how to respond, even when things get hard.)

D

9–10 - (I usually feel calm, clear, and confident about what to say or do in the moment.)

Question 12 of 13

 

(On a scale from 1-10)

How would you describe the overall emotional tone in your home right now?

A

1–3 - (Things often feel tense, unpredictable, or emotionally draining.)

B

4–6 - (There are good moments, but stress or emotional ups and downs still show up regularly.)

C

7–8 - (The home usually feels calm and connected, with occasional stressful moments.)

D

9–10 - (Our home generally feels peaceful, supportive, and emotionally manageable.)

Question 13 of 13

Is there anything else you want me to know as we begin?

Confirm and Submit