HOME HARMONY INTAKE | Raising Brain

Home Harmony Session Intake Form

This form is simply a starting point. It’s not an evaluation or checklist, it’s an invitation to share what feels helpful as we begin working together. Coaching is about collaboration, curiosity, and honoring the unique rhythms and needs of your family. There are no wrong answers, and you’re welcome to skip any questions that don’t feel relevant or comfortable to answer right now.

Parent/Guardian First Name

Parent/Guardian Last Name

Phone

Tell me a little about your family.

What supports (if any) has your family used in the past?

What brings you to family coaching at this time?

Please share a little about your child or children who may need support.

If anyone in your home has specific communication needs, please list them below

Are there specific challenges you're experiencing right now in the home (routines, transitions, regulation, sibling dynamics, independence, etc.)?

What kinds of solutions or support do you hope for from coaching?

Do you or any family members in the home identify as neurodivergent, disabled, LGBTQIA+, or part of any other community that shapes your experience and support needs?

How would you describe your parenting style?

Authoritative (supportive but firm)

Permissive (more lenient)

Authoritarian (strict and controlling)

Other

Is there anything else you’d like to share about your child(ren) or your family that could help me understand your needs better?

What days and times generally work best for coaching sessions?

Were you referred to Raising Brain?

Yes

I look forward to working with you and your family. If you haven’t heard from me within 24 hours, kindly check your spam folder as sometimes my emails may end up there due to settings. Please check this box to acknowledge.