Welcome to The Kairos Bridge!

Before our free consultation, please take 5 minutes to complete this intake form so I can better understand your child and make our time together as helpful as possible.

Family Snapshot

Parent First Name

Parent Last Name

Parent's Email

Parent's Phone Number

How many children do you have?

Name of Child

Child's Age

Current Parenting Challenges

When you think about these behaviors, what concerns you most right now?

I worry about how these behaviors are affecting my child right now (confidence, emotions, friendships, school).

I worry about how these patterns could impact my child long-term if they continue.

I suspect there may be a deeper issue behind the behavior that I don’t fully understand yet.

These behaviors are creating tension or stress within our family.

These behaviors are affecting siblings or relationships with other children.

These situations leave me feeling overwhelmed or unsure how to respond.

Other

Which of the following best describes the impact these behaviors are having right now?

My child seems frustrated, discouraged, or emotionally overwhelmed.

My child is struggling academically or with responsibilities.

My child is having difficulty with friendships or social situations.

Sibling relationships are becoming tense or conflict-heavy.

Family routines feel stressful or difficult to maintain.

I often feel unsure how to respond in the moment.

I find myself reacting in ways I later wish I had handled differently.

I’m concerned these patterns may continue as my child gets older.

Developmental Needs Snapshot

Answer the following questions on a scale of 1 star to 5 stars (1 = low/not at all and 5 = high/definitely)

Executive Function: How difficult are these skills for your child?

(1 = low/not at all and 5 = high/definitely)

Parenting Climate

Which description feels closest to how parenting usually feels in your home right now?

Our home has clear expectations and structure. When rules are broken, consequences usually follow, even if emotions run high.

We try to balance expectations and discipline with understanding. When challenges come up, I usually try to guide my child while also helping them understand their feelings and build appropriate life skills.

Some days feel chaotic or exhausting. I often feel like I’m reacting to situations rather than feeling confident about how to handle them.

I try to keep the relationship peaceful and supportive. Sometimes I avoid conflict or give extra flexibility because I don’t want things to escalate.

Which area feels hardest for you right now?

Setting clear boundaries

Staying calm when my child is upset

Following through with consequences

Understanding what my child is feeling

Staying consistent

Knowing the right response in the moment

If our work together was successful, what would change in your home?

What is the most important thing you want help with right now?

Have you already booked your consultation meeting?

Yes

No

I understand that Kairos Bridge consultations provide educational parenting coaching based on child psychology and development principles. This coaching does not replace therapy, counseling, or medical care.

Welcome to The Kairos Bridge!

Family Snapshot

Current Parenting Challenges

Developmental Needs Snapshot

Parenting Climate

Contact Me

info@thekairosbridge.com