Parent Coaching Intake | Child Safety First

Parent or caregiver 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 parent coaching 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 visit format

Mailing address

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

Primary coaching goal

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

Scheduling, preferred location, tentative start date, expected frequency, accessibility needs, and emergency contact

Payment responsibility: name, role, billing phone/email, and court or agency details

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

I understand parent coaching is educational and supportive, not therapy, medical treatment, or legal advice; court orders remain controlling; 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