Building Better Routines: Parent Intake Form

Parent First Name

Parent Last name

Child’s Name:

Child’s Age:

Date and time

Month

Day

Year

Time

HoursMinutes

Current Daily Routine

What does your family’s current weekday schedule look like? (Please describe the general flow: wake-up, meals, school/activities, bedtime, etc.)

Weekend routine (if different):

What time does your child typically:

Wake up:

Start school or learning activities:

Eat meals:

Have screen time:

Do chores (if any):

Relax/playtime:

Go to bed:

Are there any parts of your current routine that are working well?

What areas of the routine feel stressful, inconsistent, or challenging?

What would your ideal weekday routine look like for your child and your family?

What changes would make life easier for your family?

Is there anything else we should know to better support your routine planning?

Eat meals:

Breakfast:

Lunch:

Dinner:

919-332-0760