Triple P Parenting Program Request/Referral Form
FORTITUDE COUNSELING ASSOCIATES, PLLC
TRIPLE P – POSITIVE PARENTING PROGRAM
100 Westlake Rd, Ste 102
Fayetteville, NC 28314

WHAT IS TRIPLE P?

Triple P is a parenting program, but it doesn’t tell you how to be a parent. It’s more like a toolbox of ideas. You choose the strategies you need. You choose the way you want to use them. It’s all about making Triple P work for you.

WHAT TYPE OF PARENT WOULD BE BEST SUITED FOR THIS PROGRAM? (Below are examples only and not required for participation in this program.)

1) If you feel overwhelmed with your child's behaviors, or feel like your child's behaviors are just not improving or even getting worse.

2) If a judge has ordered you or your child to attend counseling for reasons related to the parent child relationship, you may be an ideal participant for this program.

3) If you want to improve the relationship between you and your child with proven methods that work.

4) If you have a child who meets symptom criteria of a mental disorder or who has been diagnosed with a mental such as but not limited to:
ADHD
ODD
Anxiety
PTSD
Conduct Disorder
Depression

WHAT ARE THE GOALS OF TRIPLE P PARENTING?
* Increase competence in promoting healthy development and managing common child behavior problems and  
    developmental issues
* Reduce use of coercive and punitive methods of disciplining children
* Increase use of positive parenting strategies in managing their children’s behavior
* Increase confidence in raising their children
* Decrease behavior problems in their children (for families experiencing difficult child behaviors)
* Improve partners’ communication about parenting issues
* Reduce stress associated with raising children

HOW DO YOU DO TRIPLE P’S POSITIVE PARENTING PROGRAM?

At Fortitude Counseling Associates, we offer 2 delivery options. Our programs are offered in-person, virtually/online, and via Hybrid- which includes in-person and virtual options.

Level 4 Group Parenting Class (8 Sessions)
        - Insurance may cover the cost of group.
        - Self-Pay options are also available for this service.

Level 4 Individual Sessions (10 Sessions)
        - Insurance may cover the cost of group.
        - Self-Pay options are also available for this service.

        * One of our Triple P Parenting Program consultants will be in contact with you to further discuss these options.

HOW DO YOU GET STARTED?

1) Complete the form below.
2) Select the delivery option you are interested in and the day of the week you would like to attend.
3) Someone will be in contact with you to schedule an intake session.

ONCE I HAVE COMPLETE THE TRIPLE P’S POSITIVE PARENTING PROGRAM WILL I RECEIVE A CERTIFICATE?

Yes. Upon full completion of the Triple P program, you will receive a certificate of completion.

WHAT IS THE COST OF THIS PROGRAM?

Cost associated with this program can be covered by 1 of 3 ways.
1) Your insurance may cover this program.
2) You may be eligible for this program for free if your child is enrolled and has recently started or will soon begin Trauma Focused Cognitive Behavioral Therapy, or another psychotherapy service at Fortitude Counseling Associates, PLLC.
3) Self-Pay the cost if self paying is $150 for the Level 4 Group Program.

Once you have submitted this form, a program representative will be able to review your payment options with you.

WHY IS THE TRIPLE P PARENTING PROGRAM BETTER THAN OTHERS?

The Triple P Parenting Program is a North Carolina grant funded program coordinated through Cumberland County Department of Public Health. Cumberland County Department of Public Health manages the grant and has sponsored Fortitude Counseling Associates, PLLC as a provider agency. The Level 4 Triple P Programs offered at Fortitude Counseling are recognized world-wide. They are also evidenced based practices with the highest CEBC ratings which means Well-Supported by Research Evidence for the area of, Disruptive Behavior Treatment (Child & Adolescent), and Parent Training Programs that Address Behavior Problems in Children and Adolescents.

For information on Fortitude Counseling Associates and the services we offer please visit: www.fortitudecounselinassociates.com

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Email *
Person Requesting Service or Submitting Referral
Person Requesting Service or Submitting Referral (If person submitting this form is the person who will be receiving the services, anwer the question below then go to the next section. *
Which delivery type are you interested in receiving? *
Level 4 Group Class Schedule
Untitled Title
Which group are you interested in attending? If you are seeking individual sessions, please indicate that below. *
Referral Agency or Organization (Skip this section if you are not being referred.)
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Phone Number
Email
Parent/Guardian 1
Parent Last Name *
Parent First Name *
Address *
City *
State *
Zip Code *
Phone *
Parent 1 Email *
Parent/Guardian 2
Parent Last Name
Parent First Name
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State
Zip Code
Phone
Parent 2 Email
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Child 8 (Last, First)
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I am the Parent/Guardian seeking services or I have discussed this request for support with the Parent/Guardian prior to submitting this form. *
Submitters Signature: By typing my name below I am verifying that the above information is accurate and true. (First Name Last Name) *
Date *
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