Positive Parenting Program

Initial Contact

Personal details

Waiver of Confidentiality

Children Details

Family Origin

Protective Services

Courts

Mental Health

Discipline

Expectations

Drug and Alcohol

Initial Contact and Intake

Have you ever attended another parenting program?

Yes No

Name of program:

How many sessions did you attended?

Do you have or can you provide documentation of your sessions, last date of attendance, progress, participation, and financial status from that agency

Yes No

Do you have a court order?

Yes No

Today's Date:

Number of weeks required:

Referring Agency or Court and County:

Case Information

Referring Agency (Court-Superior or Family/ Probation/ CPS):

Referring Agency City/County:

Name of Agency Contact (P.O, Mediator, Social Worker, Court Liaison)

Referring Agency Phone:

Referring Agency Fax:

Case/ File/ Docket/ Xref: