Register for Chime (for parents) Name * First Name Last Name Email * City where you currently live * Best # to reach you * (###) ### #### Can I leave confidential voicemail or text messages at the above number? * Yes No Emergency Contact - Name Emergency Contact - Relationship Emergency Contact - Phone Number (###) ### #### Who referred you/how did you hear about Chime? Your past experience (if any) with Mindfulness Your past experiences with therapy/therapy groups/groups of any kind (if any) and any history of mental health challenges Your child's or childrens’ current names and ages What kind of co-parenting or community support do you have with the raising and daily care of your child/children currently? How would you describe your child's or childrens’ individual disposition? What is easy/fun/lovable about your child/children and what is most challenging for you currently in parenting them? Would you currently say you are depressed or managing depression or moderate to severe anxiety? If so, please describe in as much detail as you feel comfortable What would you say are your strengths as a parent, and what skills would you most like to gain in parenting? What are you most hoping to get out of this Workshop? Thanks, your responses have been submitted.
