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* 1. Your Name

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* 2. Address-Street/Town/Zip:

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* 3. Email Address

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* 4. Phone number - indicate if NOT a cell phone

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* 5. Ages of All Children

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* 6. Name & Age of your most challenging child

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* 7. Which Workshop do you want to attend?

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* 8. How did you hear about this?

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* 9. In the last 6 weeks, how difficult would you say your most challenging child's behavior has been?

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* 10. To what extent would you say that your experience as a parent in the last 6 weeks has been rewarding?

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* 11. To what extent would you say that your experience as a parent in the last 6 weeks has been demanding?

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* 12. To what extent would you say that your experience as a parent in the last 6 weeks has been stressful?

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* 13. To what extent would you say that your experience as a parent in the last 6 weeks has been fulfilling?

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* 14. To what extent would you say that your experience as a parent in the last 6 weeks has been depressing?

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* 15. In the last 6 weeks, how confident have you felt to undertake your responsibilities as a parent?

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* 16. How supported have you felt in your role as a parent in the last 6 weeks?

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