CO/CREATE PLAY New Family Registration
Our program is different in that we want to get know you and your family to deeply serve you. This form serves as an intake form and survey for data collection as we grow our reach for more families! Thank you for signing up, we are so excited to meet you all!
Email address *
You full name *
Your answer
Are you currently: *
Required
Cell number *
Your answer
Your partner's name (if applicable)
Your answer
Your partner's cell number (if applicable)
Your answer
Please list your children's full names and ages *
Your answer
What town/city do you live in? *
Your answer
Data Collection for Program Effectiveness
The following questions will be used to assess the effectiveness of our sessions in helping families live their best lives and are 100% private. Please answer honestly, there is no judgement. We need a baseline to serve you and see where you and your family is at. We will ask these questions on a quarterly basis.
On a scale from 1-5, how would you rate your relationship with yourself? *
I dislike myself (or some aspect of myself) very much.
I love every cell in my body.
On a scale from 1-5, how would you rate your relationship with your partner? *
It's at it's lowest point.
It's mind blowingly amazing.
On a scale from 1-5, how would you rate your relationship with your kid(s)? *
It's at it's lowest point.
It's mind blowingly amazing.
On a scale from 1-5, how are you at adapting to new situations or challenges? *
I freak out!
I'm highly adaptable and go with the flow.
On a scale from 1-5, how is your family at adapting to new situations or challenges? *
They can't handle change.
We're pretty great at doing what needs to get done.
Do you suffer from any of the following? *
Required
Does your partner suffer from any of the following? *
Required
Do your kid(s) suffer from any of the following? *
Required
Why do you want you and your family to participate in our PLAY program? *
Your answer
How can we make you feel safe? Put differently, what do you need to be your truest self? *
Your answer
Is there anything else you want to tell us or ask of us? *
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service