Parent 1
First Name
{"type":"text","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Last Name
{"type":"text","name":"__generic2","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
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|---|
Parent 2
First Name
{"type":"text","name":"__generic3","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Last Name
{"type":"text","name":"__generic4","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
|---|
Children (including those from previous marriage)
Child 1
First Name
{"type":"text","name":"__generic5","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Last Name
{"type":"text","name":"__generic6","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
{"type":"radio","name":"__generic7","width":50,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Male\nFemale"}
| Age{"type":"text","name":"childAge","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Date of Birth{"type":"text","name":"__generic8","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
Adopted? {"type":"radio","name":"__generic9","width":25,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
| Through Holt? {"type":"radio","name":"__generic10","width":25,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
|
Grade {"type":"text","name":"__generic11","width":60,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Country {"type":"text","name":"__generic12","width":60,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
Child 2
First Name
{"type":"text","name":"__generic13","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Last Name
{"type":"text","name":"__generic14","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
{"type":"radio","name":"__generic15","width":50,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Male\nFemale"}
| Age{"type":"text","name":"__generic16","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Date of Birth{"type":"text","name":"__generic17","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
Adopted? {"type":"radio","name":"__generic18","width":25,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
| Through Holt? {"type":"radio","name":"__generic19","width":25,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
|
Grade {"type":"text","name":"__generic20","width":60,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Country {"type":"text","name":"__generic21","width":60,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
Child 3
First Name
{"type":"text","name":"__generic22","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Last Name
{"type":"text","name":"__generic23","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
{"type":"radio","name":"__generic24","width":50,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Male\nFemale"}
| Age{"type":"text","name":"__generic25","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Date of Birth{"type":"text","name":"__generic26","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
Adopted? {"type":"radio","name":"__generic27","width":25,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
| Through Holt? {"type":"radio","name":"__generic28","width":25,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
|
Grade {"type":"text","name":"__generic29","width":60,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Country {"type":"text","name":"__generic30","width":60,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
Child 4
First Name
{"type":"text","name":"__generic31","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Last Name
{"type":"text","name":"__generic32","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
{"type":"radio","name":"__generic33","width":50,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Male\nFemale"}
| Age{"type":"text","name":"__generic34","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Date of Birth{"type":"text","name":"__generic35","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
Adopted? {"type":"radio","name":"__generic36","width":25,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
| Through Holt? {"type":"radio","name":"__generic37","width":25,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
|
Grade {"type":"text","name":"__generic38","width":60,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
| Country {"type":"text","name":"__generic39","width":60,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
|
1. First, please follow this link to make the PACE Program payment. (By clicking this link, you will be directed to another tab.) Once you have submitted your payment, return to this page to finish registering.
2. In what ways does your family currently need support? Or what resources would help you,
your child and your family succeed?
{"type":"textarea","name":"__generic55","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
3. Are there other resources or services you have utilized for your child (i.e. speech, OT, PT, medical, etc.) If yes, when and where? Have they been successful?
{"type":"radio","name":"__generic40","width":20,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
{"type":"textarea","name":"__generic56","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
4.Does your child have any medical concerns that we should be aware of? Is your child taking any medications?
{"type":"textarea","name":"__generic57","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
5.
Most PACE sessions are conducted via video conferencing using the Zoom
platform. Are you able to participate in video conferencing or will you
need accommodations?
{"type":"textarea","name":"__generic58","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
6. What goals do you wish to accomplish after three sessions in our PACE program?
{"type":"textarea","name":"__generic59","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
7. Please tell us any additional information that will help us support your family and child.
{"type":"textarea","name":"__generic60","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
8. How did you hear about us?
{"type":"textarea","name":"__generic41","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
9. Holt's PACE (Post-Adoption Coaching & Education) program
provides coaching, not therapy, with the goal to support, educate and provide
resources for you when appropriate. Please note that the sessions you are
registering for must be completed within 6 months of your registration/payment
date, ideally within 2-3 months. If not completed within this timeframe,
your sessions expire (no refunds). By selecting "Yes," you agree to these terms.
{"type":"radio","name":"__generic42","width":20,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
