Child-Parent Relationship Training Group Interest Form

This form serves as a brief introduction to the requirements for attending this group and to gather the days and times that work best for those interested.

For more information on Child-Parent Relationship Training you can go here: https://pinontherapy.com/33-2/

If you have any questions, please contact me at 775-900-7302.

All responses will remain confidential and will not be shared outside of Pinon Family Therapy.

Sign in to Google to save your progress. Learn more
Child Parent Relationship Therapy Group Enrollment
Submission of this form does not mean that Amanda Green and Pinon Family Therapy is accepting you as a client, nor does it guarantee you will be admitted into this group.
Clear selection
The CPRT program consists of 10 sessions. The associated costs are outlined below:

1. Parent (Individual)

Per Group: $35

Paid in Full: $300 

2. Co-parent/Spouse (2 People)

Per Group: $55

Paid in Full: $500 

3. Additional Parent Figure/Spouse

Per Group: $25 additional per person, no discount if paid in full for the additional Parent/Spouse

4. Missed Groups / Makeup Sessions

Additional Cost for makeup sessions with one-on-one meetings 

Are you interested in attending in-person groups or telehealth groups? *
You must be present in Nevada to participate in telehealth-based groups.
Will you be located in Nevada during the groups?  
Clear selection

In addition to participating in the group sessions, you will be expected to complete certain activities outside of the sessions. This includes spending 30 minutes with one child and acquiring a small selection of toys.

Are you able to commit to these requirements

 *
How did you hear about the Child-Parent Relationship Therapy (CPRT) Group?
Clear selection
On a scale of 1 to 5, how motivated are you to actively participate in the group sessions and practice the new skills at home?
Not Motivated
Highly Motivated
Clear selection
Please indicate your availability for the group sessions:

 *
Available
Not Available
Monday: 12pm to 2pm
Monday: 6pm to 8pm
Tuesday: 12pm to 2pm
Tuesday: 6pm to 8pm
Wednesday: 12pm to 2pm
Wednesday: 6pm to 8pm
Thursday: 12pm to 2pm
Friday: 12pm to 2pm
Saturday: 12pm to 2pm
Sunday: 12pm to 2pm
Sunday: 2 pm to 4pm
Please mention any times that would be beneficial for you outside of the times previously mentioned.
Parent/Guardian's Full Name *
Phone Number (filling this out gives me consent to contact you and leave a voicemail mentioning your want to attend this group) *
Child/Children's Age *
What specific challenges are you currently facing in your relationship with your child or children?
What are your primary goals or expectations for participating in the Child-Parent Relationship Therapy (CPRT) Group?
Have you previously participated in any parenting classes or therapy groups?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pinon Therapy.

Does this form look suspicious? Report

Google Forms