Parent Coaching Intake | Child Safety First

Parent completing this form — full legal name

Email address

Phone number

Date completing this form

Best method of contact

Co-parent or guardian name, relationship to child, phone number, and email address (if applicable)

Your relationship to the child or children

I consent to participate in Co-Parenting in Practice services with Child Safety First.

I authorize Child Safety First to communicate with the professionals I name in this form when I provide any required release.

Requested session format

Mailing address

Child information: names, ages, your relationship to each child, and any custody or parenting-time arrangement

Primary coaching goals (select all that apply)

Child-focused communication

Conflict reduction and de-escalation

Consistent routines across homes

Parenting-time planning and transitions

Clear boundaries and respectful communication

Joint decision-making for the child

Other goals

Current challenges and relevant background: court or protective orders, prior mediation or services, safety concerns, and professionals currently involved

Scheduling: preferred days and times, tentative start date, accessibility needs, emergency contact, and any communication restrictions

Payment responsibility: name, role, billing phone/email, court or agency details, and agreed hourly rate if known

I agree not to audio record, video record, photograph, livestream, or post any session or Child Safety First staff without written permission.

I understand Co-Parenting in Practice is educational and supportive—not legal advice, therapy, a custody evaluation, or a substitute for a court order; court orders remain controlling; confidentiality is limited by law; mandatory reporting duties apply; and sessions canceled with less than 24 hours notice may be charged in full.

I certify that this information is complete and accurate to the best of my knowledge.

Child Safety First use only - approved coaching rate and effective date

I consent to Child Safety First recording sessions when necessary for documentation and using secure technology, including AI-assisted tools, to help draft service notes. I understand recordings are not shared except as required by law or authorized in writing.

Digital signature — type your full legal name

Signature date

Co-Parenting in Practice Intake

About Child Safety First

WHAT TO EXPECT