Happy Heart Parenting 



Your Subtitle text
Forms 
      Instructions: 
         Registration Form - Fill out and click 'submit.'
         Attorney Referral Form - Print and give to Attorney to fill out and FAX or mail in.
         Therapist Referral Form - Print and give to Therapist to fill out and FAX or mail in.

C O N F I D E N T I A L
REGISTRATION

*Please complete this form and click submit.*

First Name:

Last Name:

Address:

City:

State:

Zip code:

Email address:

Your cell number with area code:

Alternate phone number with area code:
(Indicate home, office...)

Which is the best number to reach you?

Is this parenting class ordered by the court?

Court Case #:

Any specific type of class?
(Co-parenting, High-conflict...)

How many weeks?

Your attorney's name:

Attorney's phone number with area code:

What is your child's name(s) and age(s):
(EX: Joey - 4, Amber - 2)

What are the name(s) age(s) of any other
children living with you?

Does your case involve drugs or alcohol?
If so, whom?

Does your case involve domestic violence?
If so, whom?

Are there any restraining orders in place between you and the other parent? If so, who?

Please list the court date (or approximate date) that you need the class completed by:

Please list any upcoming Saturday dates that would work best for you to attend a class. 

Highest grade level completed:

Have you ever taken a parenting class before?

If there is co-parenting:
Please answer the following questions about you and the other parent:
Is there peaceful direct contact?:
Is there peaceful phone contact?:
Do you have successful email communication?:
Do you communicate regularly?:
Do you collaborate to resolve all child-related issues?:
Are decisions RE: child(ren) made jointly?:
Is there consistency between households?:
Is your schedule flexible?:
Is the other parent's schedule flexible?:
Are both parents cordial?:
Are new spouses/partners cordial?:
Can parents attend the same event together?:
Do both parents share basic fundamental beliefs?:
Any topics your court order specifies covering:
Any specific topics you want covered:
What you could learn to enhance your ability to parent:

What  would improve the relationship with
your child(ren)?
Please check boxes next to topics you
might be interested in: 

                            
 

Picking your battles

 

Strong willed children
 

Child development stages
 

Different parenting styles
 

Bonding with your child
 

Explaining divorce, separation
 

Repairing relationships
 

Discussing sensitive topics with kids
 

Parenting as a team
 

Balancing work and kids
 

Nutrition, rest and wellness
 

The art of distraction
 

Child care
 

Single parenting
 

Establishing a routine
 

Step family dynamics
 

Positive Discipline
 

Teens
 

Commanding respect
 

Nurturing techniques
 

Negotiating with a difficult ex-
 

How to talk so kids will listen
 

Positive communication
 

Sibling Rivalry
 

Challenging behaviors
 

Successful visits
 

Safety tips
 

Day care
 

Potty training
 

Carseat safety
 

Easy Bedtime
 

Building self esteem
 

Rewards, Acknowledgement and praise


THANK YOU FOR COMPLETING THIS FORM! 

  


 


ATTORNEY REFERRAL REGISTRATION FORM

 

ATTORNEY INSTRUCTIONS:

Complete this form and fax it to 760-743-3477. We will contact your client and complete the registration process. We will credit your client $25 towards the cost of our program. If you have any questions, please call (760) 715-0550. Thank you for the referral.

 

PROGRAM INFORMATION:

Name:         [ ] Parenting Classes (Hours Ordered:___________)

[ ] Co-parenting Classes  (Hours Ordered:___________)

[ ] High Conflict Parenting Classes (Hours Ordered:___________)

[ ] Other_________________________  (Hours Ordered:___________)

To be completed by what date: ______/_______/___________

Are the parents to attend together?  [ ] - No   [ ] - Yes
Please fax: [ ] copy of the Certificate of Completion   [ ] Letter to the Court

Please detail what you would like the letter to state: ________________________

____________________________________________________________________________

____________________________________________________________________________


FAX to:     1. ________________________________________ FAX: (__ __ __) __ __ __ - __ __ __ __

                 2. ________________________________________ FAX: (__ __ __) __ __ __ - __ __ __ __

Is there a Restraining Order?  [ ] - No   [ ]  - Yes 

If yes – regarding whom? ______________________________________________________

Court of Jurisdiction: __________________________________________________________

Tuition (Without applicable discounts): 
                   [ ] 6 hour Certification - $225

[ ] 8 hour Certification - $245

[ ]12 hour Certification - $275            *Other discounts may apply,

                  

PARTICIPANT INFORMATION  (Your Client)

Legal Last Name: ______________________________First Name: ___________________________

Sex: [ ] - M   [ ] - F  Birth date: __ __/__ __/__ __ __ __

Address:

________________________________________________________________________________________

               (street)                                   (city)                                      (state)         (zip code)

 

Telephone:  Please place a check beside the best number to call:

o       Home -  ( __ __ __ )  __ __ __  -  __ __ __ __

o       Work -  ( __ __ __ )  __ __ __  -  __ __ __ __ (Ext.____________)

o       Cell -  ( __ __ __ )  __ __ __  -  __ __ __ __

 

Email Address: _________________________________________________________________________

OTHER PARENT:
Legal Last Name: ______________________________First Name: ___________________________

Sex: [ ] - M   [ ] - F   Birth date: __ __/__ __/__ __ __ __

Address:

________________________________________________________________________________________

              (street)                                   (city)                                       (state)         (zip code)

 

Telephone:  Please place a check beside the best number to call:

o       Home -  ( __ __ __ )  __ __ __  -  __ __ __ __

o       Work -  ( __ __ __ )  __ __ __  -  __ __ __ __ (Ext.____________)

o       Cell -  ( __ __ __ )  __ __ __  -  __ __ __ __

 

Email Address: __________________________________________________________________________

 

ATTORNEY INFORMATION:

Last Name: ___________________________________ First:________________________ MI:________

Address:

________________________________________________________________________________________

               (street)                                  (city)                                       (state)         (zip code)

 

Email Address: __________________________________________________________________________

FAX: (__ __ __) __ __ __ - __ __ __ __

OFFICE: (__ __ __) __ __ __ - __ __ __ __ (Ext.____________)


*************************************************************************************** 

The above named participant is registering for a program offered by Happy Heart Parenting, a San Diego County court-approved provider. This service is offered for parents who have been court ordered to complete parenting classes and Happy Heart Parenting, its agents and employees are not engaged in rendering legal, business, mental health, or other professional services. The participant is hereby notified that Happy Heart Parenting will not voluntarily disclose participant information, except: non-identifying information used for research, educational or reporting purposes; with the written consent of the participant; where ordered to do so by an appropriate judicial authority; where required to do so by law; or where the information disclosed suggests an actual or potential threat to human life or safety, or where a mandated reporting obligation exists as defined by the laws of the State of California. The participant agrees that Happy Heart Parenting, it agents, employees and directors are in no way liable for any act or omission in connection with the release of information in connection with any aspect of my participation in, or any other aspect relating to the provision of this program.

I agree to indemnify and hold Happy Heart Parenting, its employees, agents and directors harmless from any claims for damages that may arise pertaining to any aspect of my involvement with this program.

 

________________________________________________________________________________________

Attorney Signature                                                                                      Date

  

 ********************************************************************************************************************


Received: _____/_____/_____   Initials: _______      Registration Complete: _____/_____/_____   Initials: _______ 

 

Contact:   _____/_____/_____   Initials: _______                 Class Complete: _____/_____/_____   Initials: _______

 

Happy Heart Parenting • Post Office Box 28022 • San Diego, CA 92198
760-715-0550, FAX: 760-743-3477


THERAPIST REFERRAL REGISTRATION FORM

 

THERAPIST INSTRUCTIONS:

Upon the request of your client, please complete this form and fax it to 760-743-3477. We will contact your client and complete the registration process. We will credit your client $25 towards the cost of our program. If you have any questions, please call

(760) 715-0550. Thank you for the referral.

 

 *****************************************************************************************


I, __________________________ am requesting that my therapist complete this referral

form so that I may obtain a discounted tuition for Happy Heart Parenting classes. If initialed, I agree he/she may provide suggestions helpful to Happy Heart Parenting

in terms of what parenting materials might be most helpful to me.

 

  *______  -  PROVIDE SUGGESTIONS

(*Initial if ‘Yes’)

 

____________________________________________   _______________

(Client Signature)                                                  (Date)

 

  *****************************************************************************************


 

 

 

 

PROGRAM INFORMATION:

Name:         [ ] Parenting Classes

[ ] Co-parenting Classes 

[ ] High Conflict Parenting Classes

[ ] Other_________________________ 

Are the parents to attend together?  [ ] - No   [ ] - Yes 

                  

PARTICIPANT INFORMATION  (Your Client)

Legal Last Name: ________________________________First Name: ___________________________

Sex: [ ]  - M   [ ]  - F         Birth date: __ __/__ __/__ __ __ __

Address:

__________________________________________________________________________________________

               (street)                                   (city)                                       (state)         (zip code)

 

Telephone:  Please place a check beside the best number to call:

o       Home -  ( __ __ __ )  __ __ __  -  __ __ __ __

o       Work -  ( __ __ __ )  __ __ __  -  __ __ __ __ (Ext.____________)

o       Cell -  ( __ __ __ )  __ __ __  -  __ __ __ __

 

Email Address: __________________________________________________________________________

 

OTHER PARENT: (OPTIONAL)

Legal Last Name: ________________________________First Name: ___________________________

Sex: [ ] - M   [ ] - F           Birth date: __ __/__ __/__ __ __ __

Address:

__________________________________________________________________________________________

               (street)                                   (city)                                       (state)         (zip code)

 

Telephone:  Please place a check beside the best number to call:

o       Home -  ( __ __ __ )  __ __ __  -  __ __ __ __

o       Work -  ( __ __ __ )  __ __ __  -  __ __ __ __ (Ext.____________)

o       Cell -  ( __ __ __ )  __ __ __  -  __ __ __ __

 

Email Address: __________________________________________________________________________

 

THERAPIST INFORMATION:

Last Name: ___________________________________ First:________________________Title:________

Address:

__________________________________________________________________________________________

               (street)                                   (city)                                       (state)         (zip code)

 

Email Address: __________________________________________________________________________

FAX: (__ __ __) __ __ __ - __ __ __ __

OFFICE: (__ __ __) __ __ __ - __ __ __ __ (Ext.____________)

 

The above named participant is registering for a program offered by Happy Heart Parenting. This service is offered for educational purposes only and Happy Heart Parenting, its agents and employees are not engaged in rendering legal, business, mental health, or other professional services. The participant is hereby notified that Happy Heart Parenting will not voluntarily disclose participant information, except: non-identifying information used for research, educational or reporting purposes; with the written consent of the participant; where ordered to do so by an appropriate judicial authority; where required to do so by law; or where the information disclosed suggests an actual or potential threat to human life or safety, or where a mandated reporting obligation exists as defined by the laws of the State of California.

 

__________________________________________________________________________________________

Therapists’ Signature                                                                                      Date

  

 *****************************************************************************************


 

 

 

 

IF APPLICABLE: Suggestions helpful to Happy Heart Parenting Facilitator in terms of what parenting materials might be most helpful to your client: (All suggestions will remain confidential.)

 

_______________________________________________________________________________________________________

 

_______________________________________________________________________________________________________

 

_______________________________________________________________________________________________________

 

_______________________________________________________________________________________________________

 

 *****************************************************************************************


Received: _____/_____/_____   Initials: _______          Registration Complete: _____/_____/_____   Initials: _______ 

 

Contact:   _____/_____/_____   Initials: _______                    Class Complete: _____/_____/_____   Initials: _______

 

Happy Heart Parenting • Post Office Box 28022 • San Diego, CA 92198
760-715-0550, FAX: 760-743-3477
 



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