New+Hope+Parenting+Solutions%2C+Heather+Ackley+MSW%2C+parental+guidance%2C+siblings%2C+problem+child%2C+parent — Application Process

Applications are only for people who would like to participate in individual and class settings.
In order to qualify for individual or class settings, we request that you complete the application process. All applications can be submitted via email, by filling out the form below, or in person. Once applications are received, they will be screened and an interview will be set up. It is important to remember that NHPS staff are focused on quality supports that are the best fit for your family. Please note that any adult that has legal custody of the child will need to agree to services in writing before we can begin working with your family.

Application

To apply for services, please fill out the form below. Fields marked with * are required.

Today's Date

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

Partner's Name

First Name

Last Name

Partner's Date of Birth

YYYY

Child Name

First Name

Last Name

Child Date of Birth

YYYY

Child Name

First Name

Last Name

Child Date of Birth

YYYY

Child Name

First Name

Last Name

Child Date of Birth

YYYY

Child Name

First Name

Last Name

Child Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reason for Applying

Any Mental Health Diagnosis

For the children or adults in the home.

Any Medical Concerns

For any adults or children in the home.

Do you feel the way you are parenting is contributing to the behaviors you are concerned about?

What percent of the time do you follow through with negative consequences?

Like discipline, time outs, groundings, losing TV or screen time?

What percent of the time do you follow through with positive consequences?

Like rewards, going to the park, going to a friends house, etc?

What parenting techniques have you tried so far?

How long did you try each of the parenting techniques?

How do you feel the parenting techniques worked or didn't work?

Does anyone that will be working with NHPS have a legal history? If so, please explain.

Is there anything else you feel we should know about your family?

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Application Process

Applications are only for people who would like to participate in individual and class settings.

Application

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