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Behavior Plan Request

I am interested in working with ADD Coach Services to develop a customized Behavior Modification Plan for my family. I have made a payment of $49.99 to PayPal and would like to schedule a 30 minute consult to help develop the plan.* _________________________________________________________________________________________________________________

* Required fields
Name *
E-mail Address *
Town *
State *
Phone Number
Fax Number
Marital Status *
Number of Children *
List Name and Age of Each Child *
Have Any of Your Children Been Diagnosed with ADD *
If you answered yes please give child's (children's) name. *
Have you ever usd a behavior plan to discipline before? *
Are any of your children taking medication for any mental health diagnosis? *
If so, please provide each child's name, & the name and dose of the medictaion .
Please describe your present form of discipline. *
Are parents in agreement about how to discipline? *
Please discuss any differences parents have concerning disciplinary methods. *
Is any one child more difficult than the others to discipline? *
Please list children in order of discipline difficulty, from the hardest to the easiest. Include any diagnosis of each child. *
What are the most problematic issues regarding discipline? *
What disciplinary methods have you tried that have failed? *
What form of dicipline has worked best so far? *
Please share whatever else you think I need to know about your situation that is pertinent to your child's behavior and your parenting. *

I have read and agree to the Privacy Policy *

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*  UNSURE IF A BEHAVIOR PLAN IS RIGHT FOR YOUR CHILD?

    PLEASE BE SURE TO REQUEST A FREE  CONSULT BEFORE DECIDING!