Parent Coaching Pre-Program Survey

Baseline Assessment - Session 1

Your Name *

Initials *

Survey Date

November 12, 2026

Section A: Demographic Information

Zipcode *

Primary language spoken at home *

Section B: Background Information

Number of children *

Ages of children *

This is my: *

First time receiving parenting support

I've received support before

What are your top 3 goals for this coaching program? *

Goal 1

Goal 2

Goal 3

Section C: Parenting Confidence

Rate your current confidence level (1 = Not at all confident, 5 = Very confident)

Section D: Current Parenting Skills

Rate how often you use these strategies (1 = Never, 5 = Always)

Section E: Support & Well-being

I have adequate support in my parenting role: *

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