First Name *

Last Name

Email *

Phone

My child follows my directions. *

The first time.

After I repeat myself 2-10 times.

When I raise my voice, threaten, or entice with a reward.

Sibling rivalry is a problem in our home. *

No

Yes

Sometimes

Spending an entire day with my child(ren) is exhausting. *

No

Yes

Sometimes

My child has temper tantrums, slams doors, screams, hits, or throws things in anger. *

No

Yes

Sometimes

I can easily and effectively discipline my child. *

No

Yes

Sometimes

My child interrupts me. *

No

Yes

Sometims

My child respects the boundaries I set. *

No

Yes

Sometimes

My spouse and I are on the same page regarding our child(ren). *

No

Yes

Sometimes

Technology/screentime is a concern of mine. *

Independently - I will help briefly when asked

With me or it won't get time

Independently but I check all work

School mornings are: *

Stressful

Orderly

Getting the kids to bed is: *

Sometimes a struggle

Rarely a struggle

Always a struggle

My children go to sleep: *

In their own beds

In our bed

I/we lay down with them until they fall asleep

My kids typically eat: *

What I prepare with little to no fuss

What I prepare but I have to prepare it a special way

A separate "meal" from the family or else they won't eat

What basically described your parenting philosophy? *

Children should have an equal voice in decision-making

Children should be heard, but I make the final decisions

Children should be seen and not heard most of the time

My children: *

Have regular age appropriate chores on a daily basis

Have no time for chores between homework and after-school

Deserve to be children and don't need to be burdened with chores

What else do you want me to know about? *

I give my explicit consent to Katherine Saltzberg to collect and store my answers from this form. *

Yes

No

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