The Parent Factor Application Form

First Name *

Last Name *

Phone *

Email *

Address

City

State

Postal code

Please describe your current family situation *

What are your Top 3 Immediate concerns? *

What does your current schooling look like? *

Please list the people on your immediate support team... *

If you could wave a magic wand and fix one thing: what would that be and what would it fix? *

What are your goals for the next 90 days? *

Here are the list of common challenges children and parents are facing... PLEASE check all of the following boxes that apply: *

Behavior

Listening

Speaking

Reading

Writing

Spelling

Mathematical

Academic Performance

Interpersonal Relationships

Depression & Motivation

Under Normal Circumstances, What is your primary concern : *

Individual Behavior

Rules & Expectations

Group Behavior

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.