Annual Family Support Group Intake FormName(Required) First Last Partner/Spouse Name First Last Email(Required) Phone Number(Required)City where you live:(Required)What county do you live in?(Required)Alameda CountyContra Costa CountyMarin CountyNapa CountySan Mateo CountySan Benito CountySan Francisco CountySanta Clara CountySanta Cruz CountySolano CountySonoma CountyOtherIf "other" please elaborate (county).(Required)Church or place of worship:(Required)What support group(s) are you apart of?(Required) Berkeley Support Group Lafayette Support Group Livermore Support Group Los Altos Support Group (relaunch TBD) Los Gatos Support Group Monthly Online Support Group Morgan Hill Support Group (launch TBD) Palo Alto Support Group Parents of Teen + In-Person Support Group (launch TBD) Parents of Teen + Virtual Support Group Redwood City Support Group (relaunch TBD) San Carlos Support Group (launch TBD) San Francisco Support Group San Jose Support Group Santa Rosa Support Group (launch TBD)What are you seeking when attending this support group?(Required)Are you a single parent?(Required) Yes NoDo you have a village of support or respite options when you need them?(Required)Adult dietary restrictions to consider when planning refreshments or meals?(Required)What level of commitment are you aiming for with your family’s monthly attendance?(Required) Monthly When time permits Unsure OtherIf other, please explain:(Required)Are you currently fostering and accepting new placements?(Required)What topics would you like covered from our three pillars of video curriculum in our Attachment, Trauma and Foster/Adoptive Parenting Support Groups?(Required) Attachment style of parent Strengthening Attachment Trauma informed parenting Trust Based Relational Intervention (TBRI) Ambiguous Loss Openness in Adoption Transracial Adoption Intersection of Adoption and Race Big Behavior Management Self Regulation Self Care Collaborative Problem Solving OtherIf other, please explain:(Required)Is there anything or resource your family needs at this time?(Required)What would strengthen your family at this time?(Required)Would you like more information about other Help One Child programs?(Required) Signs of Hope Camp (7-11 years of age) Parent Training Seminars in person Virtual Monthly Parent Trainings Support Groups offered virtually Support Groups offered in person Teen Support Group Parents of Teens+ (parenting 13-21 year olds) Respite/Parent Night Out Events CarePortal One to One Virtual Childcare matching during virtual trainings or Support Groups for HOC Family Services Giving Tree @ Christmas Parents of Teens+ (parenting 13-21 year olds) Support Groups Facebook Closed Group, Blog, or PodcastDid your family form through (check all that apply):(Required) Foster Care Fost/Adopt Kinship Placement Relative/Kin Placement International Adoption Private Adoption OtherIf other, please explain:(Required)Do you have any additional comments?Do you plan on having your child(ren) attend childcare?(Required) Yes NoHow many kids would you like to sign up?(Required) 1 2 3 4 5Child #1 Name First Last Child #1 Birthdate MM slash DD slash YYYY Child #1 AgeHow long has child #1 lived with you?Is there a possible move to a new placement during this academic/support group year for child #1?Are there any specific ways we can support child #1 during childcare?What strategies or scripted phrases work at home with your child (#1) for transitions, dysregulation, upsets, conflicts, etc.?Any dietary restrictions for child #1?Additional comments for child #1?Child #2 Name(Required) First Last Child #2 Birthdate(Required) MM slash DD slash YYYY Child #2 Age(Required)How long has child #2 lived with you?(Required)Is there a possible move to a new placement during this academic/support group year for child #2?(Required)Are there any specific ways we can support child #2 during childcare?(Required)What strategies or scripted phrases work at home with your child (#2) for transitions, dysregulation, upsets, conflicts, etc.?(Required)Any dietary restrictions for child #2?(Required)Additional comments for child #2?(Required)Child #3 Name(Required) First Last Child #3 Birthdate(Required) MM slash DD slash YYYY Child #3 Age(Required)How long has child #3 lived with you?(Required)Is there a possible move to a new placement during this academic/support group year for child #3?(Required)Are there any specific ways we can support child #3 during childcare?(Required)What strategies or scripted phrases work at home with your child (#3) for transitions, dysregulation, upsets, conflicts, etc.?(Required)Any dietary restrictions or allergies for child #3?(Required)Additional comments for child #3?Child #4 Name(Required) First Last Child #4 Birthdate(Required) MM slash DD slash YYYY Child #4 Age(Required)How long has child #4 lived with you?(Required)Is there a possible move to a new placement during this academic/support group year for child #4?(Required)Are there any specific ways we can support child #4 during childcare?(Required)What strategies or scripted phrases work at home with your child (#4) for transitions, dysregulation, upsets, conflicts, etc.?(Required)Any dietary restrictions or allergies for child #4?(Required)Additional comments for child #4?Child #5 Name(Required) First Last Child #5 Birthdate(Required) MM slash DD slash YYYY Child #5 Age(Required)How long has child #5 lived with you?(Required)Is there a possible move to a new placement during this academic/support group year for child #5?(Required)Are there any specific ways we can support child #5 during childcare?(Required)What strategies or scripted phrases work at home with your child (#5) for transitions, dysregulation, upsets, conflicts, etc.?(Required)Any dietary restrictions or allergies for child #5?(Required)Additional comments for child #5?Δ
