Parenting Coaching Intake Form | EduTarbiyah Institute

1. Parent Information

Basic details to connect and prepare your session

Full Name *

Age *

Relationship with Child *

Preferred Contact Method *

Contact Number / Email *

Total Number of Children *

2. Child Information

Provide details about the specific child this coaching session focuses on

Child's Name / Nickname *

Child's Age *

Gender *

Boy / لڑکاGirl / لڑکی

Education Level

Three Good Qualities of Your Child

3. Main Parenting Challenge

Identify what is causing frustration and friction at home

4. Your Response as a Parent

Understanding how you naturally react during stressful moments

5. Parent–Child Relationship

Evaluating connection, communication, and emotional openness

6. Family & Home Environment

Household synchronization, co-parenting harmony, and external stressors

Do you and your partner generally agree on parenting rules & discipline?

Yes, mostlySometimesNo, frequent conflict

Is there any specific family situation affecting the child?

7. Desired Transformation & Goals

Concrete positive outcomes you want to achieve through coaching

What are the top 3 changes you want to see in your child/home?

What is your single biggest parenting goal right now?

8. Parental Self-Development

Children mirror who we are—committing to personal growth

What change do you want to bring in your own parenting habits?

What do you expect from this coaching program?

Are you ready to practice home exercises & daily action assignments?

Yes, fully committedWill try my bestNot sure yet

9. Additional Information

Anything else you want Dr. Younus Khalid to know before your session starts

Ready to Begin Your Coaching?

When you submit, your diagnostic responses are instantly formatted and delivered directly to the EduTarbiyah counselor team on WhatsApp for session scheduling.