Pre-course Assessment Form – CHIME Mental Health & Parenting Online

This form will ask questions about your current parenting and family dynamics. All answers will remain confidential.

Pre-Course Assessment form - Online CHIME MH Parenting

First Name

Last Name

Additional household members

Please add the details of any additional members in your household

Click on the + symbol to add the next household member

First Name	Last Name	Date of birth	Gender	Is this household member of Aboriginal or Torres Strait Islander origin?	Does this household member identify as having a disability, impairment or long-term condition?	Is this household member from a culturally or linguistically diverse background?

Access to complete an online course

If the answer is no to any of the following questions, you may not be suitable for the course. We suggest that you speak to family/friends to see if they are able to help, otherwise a face to face course may be more suitable.

Do you have access to a computer/laptop?

Yes

Are you able to install and use zoom on your computer? (if no, do you have someone who can help you set it up before the group commences?)

Yes

Do you have stable internet and enough data for a 2 hour video call each week?(Each weekly session will take 1-3 gigabytes of data depending on your video settings)

Yes

Can you confirm you have 2 hours each week to participate uninterrupted? (If children are at home is there someone who can care for them while you are in the session?)

Yes

Pre-course assessment

The following questions ask about your current parenting and family dynamics, and is used by facilitators to help determine the best way to support you in your parenting role.

Have you attended other parenting courses?

Yes

Did you complete all of the sessions?

Yes

If there was one goal you would like to achieve by completing this course, what would this be/look like?

If other, please specify

Are your children in your care:

Full-time

Part-time

Are you co-parenting?

Yes

Are there any diagnosis, disabilities or particular challenges you would like support with?

Have you been involved/ participated in mediation and/or Family Law Court proceedings/ AVO’s?

Yes

Was it recommended you attend specific parenting courses?

Yes

Have you experienced a mental health issue (past or present)?

Yes

Is your child/ren aware that you have experienced mental health issues?

Yes

Have you spoken to your child/ren about your mental health?

Yes

Are there any factors that impact on your parenting at present? This information will not be shared in the group, but will allow the facilitator to understand how to best support you in your parenting.

Do you have links to other parents, support people or services in your life at the moment?

Service support

Family

Friends

Are you currently working with another service provider or community organisation?

Yes

Do you know the location, dates and times?

Yes

No - a copy of the flyer will be emailed to you

Do you have a fine with the State Debt Recovery Office? You may be eligible to apply for a Work Development Order (WDO).

Yes - someone will contact you to discuss

We'd love to hear from you - get in touch today

At Central Coast Family Support Services we acknowledge the traditional custodians of this land, the Darkinjung people. We acknowledge the strong kinship networks and positive parenting practices that Aboriginal people have successfully used for tens of thousands of years before us, and continue to use today.

Family Support
Program

Family Support Program

Early Intervention Support

Young Parent
Program

Child & Family
Services

Grandparents & Grandchildren

Child & Family
Services

Children with Additional Needs

Pre-course Assessment Form – CHIME Mental Health & Parenting Online

Additional household members

Access to complete an online course

Pre-course assessment

We'd love to hear from you - get in touch today

Family Support Program

Family Support Program

Early Intervention Support

Young Parent Program

Child & Family Services​

Grandparents & Grandchildren

Child & Family Services

Children with Additional Needs

Pre-course Assessment Form – CHIME Mental Health & Parenting Online

Additional household members

Access to complete an online course

Pre-course assessment

We'd love to hear from you - get in touch today

Family Support
Program

Young Parent
Program

Child & Family
Services

Child & Family
Services