Extended Intake Form

"*" indicates required fields

Parent Interview Form

Please Answer Every Question Before Submitting this Form

Today's Date*

Date of Birth:*

Case Number:*

Report to:*

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Work Phone

Cell Phone

Email Address*

Enter Email Confirm Email

Ethnicity or Culture

Emergency Information, Name:*

Emergency Information, Phone:*

List Children: By Name, Age and Where They Live:*

ie: With You, Ex-Partner, Foster Care, Residential Care, With a Family Member

Name

Age

Where they are living

Name of other parent the child resides with or visits

List other people living in your home:

ie: Roommates, In-Laws, Friends, Partners, Step-Children, Foster Children, Nanny, Etc.

Explain Why You Are Here:*

i.e. volunteer because of problems, divorce, separation, social worker recommended, court-ordered etc

Was there a specific event that brought you here? Be specific.*

Who was responsible for the event or choice that brought you here? What do you want to learn from that choice? Explain.*

Are you seeing a physician or mental health professional? Tell us what your conditions are

Tell us if there is any history of drug/alcohol abuse, sexual or neglect accusations against you.*

Are there any criminal issues pending such as restraining orders, court hearings for termination or divorce proceedings?*

Any special need kids in your home?*

Describe stresses such as job problems, divorce/relational issues, parent/child conflicts, etc.*

How would you describe yourself as a child? (honest, well-mannered, rebellious, shy, angry, etc.) Describe a childhood event that demonstrates your character.*

What do you remember about how you were disciplined as a child? Were you spanked, yelled at, ignored, talked to, redirected, restricted, had things taken away, neglected, abused, etc? Please be detailed.*

How do you believe children should be disciplined? Be specific. Describe given choices, punished, have consequence, experience out comes, etc.*

What do you recognize as your parenting strengths?*

What are your challenges?*

Do you have any questions?

Which class do you want to take?*

Please let us know which of our classes you feel is more suited for you.

Consent To Release Of Information

I hereby authorize Break Through Learning Center to disclose information regarding participation in parenting classes, parenting plans, mediation, consultation or parent coaching or supervised visitation to all parties listed below:

Name

Address

Phone

I give permission to Break Through Learning Center and to individuals and/or all organizations listed above including all agents of DSHS or Criminal or Family Court officials to exchange information about my completion of class assignments, absences, educational assessments, visits and recommendations. I, give permission for the following person or persons to drop off and pick up my child from visitation as agreed on in the intake plan:

Name

Address

Phone

Participant Agreement Form

Participant Agreement Form for: Online/In-class Parent Education Courses

Consent*

All Participants Agree to the following:

Break Through Learning Center courses are educational and do not provide individual assessments or counseling. Certified Break Through Learning Center instructors are strictly educators, not therapists or counselors and provide parent education without intent of counseling.

Break Through Learning Center Refund Policy. The client must pay in advance of services. A 15-day notice of cancellation of courses before the 1st day of class is due for a full refund minus the non-refundable interview ($125) and minus ($25) cancellation fee. If the client drops after the 1st day of class or does not attend the first class, no fees will be returned to the client, but the client may reschedule another class or apply the tuition to other services. No fees refunded to the client after the 1st week of class.

Attendance is Mandatory. If you miss a class or coaching session, you pay $25, and add a make up class or session. Miss two classes and you are given a warning. Miss three class, automatic suspension which mean re-enrollment.

The purpose of Break Through Online Learning is:
a) to improve the relationship between parent and child;
b) to lower family conflict;
c) to understand the stages of human development; and
d) to acknowledge the impact separation and divorce have on children.

All Participants Agree to the following online class guidelines:
• To attend all scheduled classes or meet with a parent coach
• To view video lectures
• To respond to reflection notes, assignments and online discussions.
• To keep information confidential when participating in discussions
• To be responsible for making agreed payments on time if not paying in advance.
• To complete ongoing surveys & self-evaluations
• To accept recommendations from trained facilitators

All Participants Agree to the following class requirements:

1. MANDATORY ATTENDANCE in a 12-week cycle IN CLASS OR 30 MINUTE PARENT COACHING weekly. Certificates will not be given if parents do not attend all 12 classes in a course.

2. NO SIGN IN if participant is more than 15 minutes late to class; must arrange coaching.

3. Not to hold Break Through Learning Center responsible for the loss or destruction of any personal property or will not hold the Institute responsible for any accidents or injuries while attending parenting classes on the Roosevelt Suite premises.

4. Not to engage in disruptive behavior in class or online that may be perceived by the facilitator or group to be harassing or violent.

Participants may call (206) 992-2831 for information regarding class assignments, directions or general information, but not for consultation or mediation without prior agreement.

I agree to the above policies and will follow them to the best of my ability: