Parent informationName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Do you live in Travis or Williamson County?*YesNoBest time to contact (day and time)Email* Enter Email Confirm Email PhonePrimary child name*Primary child date of birth* Date Format: MM slash DD slash YYYY Number of children, ages 0-5, living in the home*Please enter a number from 0 to 5.Number of children, ages 6 or older, living in the home*Please enter a number from 0 to 25.Preferred language (check all that apply)* English Spanish ASL Other If other language is preferred, which language(s)Is parent Deaf, DeafBlind, DeafDisabled, or Hard of Hearing?YesNoIs parent's child Deaf, DeafBlind, DeafDisabled, or Hard of Hearing,?YesNoPreferred service type* Individual Session Group Session No Preference Preferred service time* Morning Afternoon Evening Preferred service day* Monday Tuesday Wednesday Thursday Friday Preferred curriculum typeTriple PNurturing parentingFatherhoodParents as teachersNo preferenceHave you or are you currently experiencing any of the following? (check all that apply)* Difficulty with parent/child interaction Parent/Guardian and/or child suffers from depression/anxiety Teen parent High parent conflict/separation/divorce High general stress level Parent/guardian has high frustration level with child's behavior Parent/guardian would benefit from child development education Social isolation of family/parent/guardian-lack of support Homelessness Non-traditional family structure-especially single parent with lack of social support and/or a high number of children in the household Low income Substance abuse Low education Parent experienced maltreatment in childhood Survivor of domestic violence Parenting a child with special needs (if selected, please provide additional info below) Current or former foster youth parent If child has special needs, please provide information about those needsDo you wish to complete your parenting classes in person, over the phone, or virtually?In personOver the phoneVirtually (Zoom, FaceTime, Skype, etc.)Do you have access to the internet and a device that will allow you to participate in virtual classes?YesNoHow did you hear about Strong Start?From a friend or family memberFrom my child’s schoolFrom my child’s doctorFrom my churchI saw a flyerI saw it on social mediaI heard about classes on the radioI heard about classes on TVI attended a community event and talked to a representativeOther (please tell us more below)Please tell us more about your answer to the previous question. (For example, if you answered "From my child's doctor," please tell us who the doctor is or the name of the clinic. Or if you answered "Other," please tell us more.)Permission: MUST BE COMPLETED BY PARENT* By checking this box, I (parent) give permission for this referring agency to give the following contact information to Strong Start and Project HOPES staff as part of a referral process to the Strong Start program. I agree for my contact information to only be utilized for referral purposes and only to be released to Strong Start and Project HOPES staff. Date* Date Format: MM slash DD slash YYYY Referring agency informationNameAgency nameTitleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail Is parent currently engaged in an open CPS case?YesNoHas the family had a substantiated CPS case?YesNoIs parent education court ordered?YesNo