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ThirdMind Sacred Parenting Private Program

PRIVATE PROGRAM INTAKE FORM

Welcome! We're eager to tune in with you and come alongside you in your parenting journey. Please fill out the intake form below to complete your registration.

First Name

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Last Name

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Email

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Phone Number

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Briefly describe your roll in relation to parenting.

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What are the 2 primary parenting challenges you are currently facing with your child(ren)?

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What is your relationship with spirituality and how does that show up in your life and parenting?

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Describe the age group of your child or children.

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(Newborn, toddler, middle school, high school, adult)

What are your goals for participating in the ThirdMind Parenting program?

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What do you hope to get out of this experience?

How would you describe your current level of stress or overwhelm in your parenting role?

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(low, moderate, high)

We offer a Cohort, group program. Please describe why you prefer to utilize our private offering.

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What specific behaviors or emotional challenges in your child(ren) would you like to address?

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(defiance, stress, self loathing, anxiety, withdrawal, etc.)

How would you rate your commitment level to this program?

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How would you rate your commitment level to this program?

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Are there any cultural, spiritual, family, or personal factors that you feel should be considered in tailoring the program to your needs?

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Where are you located and are you willing and available to show up for in person meeting near Encinitas, CA?

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Thanks so much for taking the time to thoughtfully answer these questions. We look forward connecting with you!