Conscious Co-Parenting: About You - Your Goals & Objectives

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This form is completely confidential and will only be used by Radhika Lakhani to assist you in getting the most out of this program.

Name *

Your child's or children's age and gender *

What are your biggest personal challenges with your separation and divorce? *

What are the biggest challenges you encounter when co-parenting with the other parent and/or parenting solo (as it applies to you)? *

Why are you motivated to overcome these challenges now? *

What do you think has prevented you from overcoming these challenges so far? (if anything) *

Why are you interested in this program as a solution to these problems? *

What are you hoping to get out of this program (a.k.a. objectives) *

What is the impact you hope this program will have on your children through this work? *

How do you take care of YOU? *

What are your daily self-care practices and/or coping mechanisms? *

What are the topics you would love to see addressed? *

What is the best way we can support you? What does support look like to you right now? *

Is there anything else you'd like to share, so that I can best support you and your child(ren)? *

Describe how you will feel if you were able to accomplish some of your objectives listed above! *

How committed are you to seeing a shift? *

Not at all committed

I'm ALL IN!

In this program, we wish to create a safe and inviting space to discuss the challenges you face as co-parents and/or solo parents. Some of the information you share in the group may be sensitive, private, and confidential information. We trust that you will agree that all information that is shared during the course of the Program is strictly confidential and shall not be shared with any other parties outside of the program at any time. *

I acknowledge and agree to hold in strict confidence all information shared by all participants in this program.

I understand that the Conscious Co-Parenting Program is being hosted in a small group format. As a result of the group format, I or Radhika Lakhani may share that I am a client of hers, in the context of this program. I may also share any further details about my personal life that are otherwise solicitor client privileged, with the members of the group during the sessions, and I understand that if I do so, that I am waiving solicitor client privilege in that context for discussion and learning purposes. *

I confirm and agree.

Not applicable. I am not a current or former client of Radhika Lakhani.

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