Safe Harbor - Your Family Story

This document is yours. There is no deadline and no pressure. Fill in what you can, when you can. What you share here will allow us to come to your consult call already holding the picture — so that your 30 minutes with us can be focused entirely on what comes next."

Section 1 - About Your Family

The adults in the household and your basic contact information

This helps us understand whether caregiver alignment is part of what we need to address.
Check all that apply

Section 2 - About Your Child

The child you are seeking support for

Note: You do not need to share your child's full name. A first name or initial is completely fine.

Check all that apply
Check all that apply based on what you know or have been told

Section 3 - What Is Happening Right Now

The most important section. Take your time.

You do not need to write perfectly. You do not need to organize your thoughts. Just tell us what is happening in your home right now, as honestly as you can.

Check all that apply

Section 4 - System Involvement

Who else is already in the picture

Check all that apply

Section 5 - Your Current Provider Team

Who is working with your child and family right now

Check all that apply
Therapies, programs, interventions, placements - list what you've tried and what happened. This helps us avoid repeating dead ends. 

Section 6 - Records & Documentation

What exists and what we may need to gather

Check all that apply, even if incomplete or hard to find

Section 7 - What You Need Most

Help us understand where to focus first

Check all that feel urgent
What does 'better' look like to you?
This asks about the CAREGIVER, not the child. You. This matters to us.