Healthy Relationships & Parenting Intake

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C.R.I.P.S.

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❤️ Healthy Relationships & Parenting Intake Form

First name

Last name

Birthday

Month

Day

Year

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Company name

Position

VAT ID

Gender Identity

Preferred contact method

Are you currently parenting a child (biological, adopted, or step)?

Yes

How many children do you currently support or care for?

Are you a single parent?

Yes

Are you in a current relationship?

Yes

How do you describe your current relationship?

What areas are you most interested in? (Check all that apply)

Co - Parenting Strategies

Communication & Conflict Resolution

Breaking Generational Cycles

Building Self-Esteem

Anger Management Skills

Establishing Boundaries

Understanding trauma & Emotional Triggers

Raising Kids with Love, not Fear

Building trust after Betrayal

Parenting as a formerly incarcerated person

Other

Have you participated in any parenting or relationship workshops before?

Yes

What is your biggest challenge in relationships or parenting right now?

What would success look like for you after completing this program?

Are you willing to participate in workshops, group circles, or 1 - 1 couching?

Yes, I'm open to all of it

I prefer group sessions

I prefer private sessions

Not sure yet - depends on the schedule

Consent to be contacted by C.R.I.P.S. for parenting & relationship support services.

Yes

Yes, I agree to be contacted for upcoming sessions, follow-up, or related resources.

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