Name: 1-2-3 Magic and Emotional Coaching (Mandurah)
Start: 2025-03-05T10:00:00+08:00
End: 2025-03-05T12:00:00+08:00
Location: Falcon Library

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Thanks for your interest in PCWA. We look forward to meeting you! To enrol in the program of your choice, please fill out the questions below. These questions help us to source better programs for your parenting needs. If your internet connection is poor, you can also call us to enrol instead.

Program details

1. Town or Suburb you live in(Required)

2. Postcode(Required)

Parent/Carer details

3. Full name(Required)

First Last

4. Preferred contact number(Required)

5. Alternative contact number

6. Email(Required)

7. Gender(Required)

Female

Male

Diverse Gender Identity

8. Age(Required)

Under 18 years

18 - 24 years

25 - 34 years

35 - 44 years

45 - 59 years

60 years and older

Family composition

Tell us about yourself and your family.

9. What best describes you?(Required)

Couple family with no children

Couple family with children

One parent family with children

Grand-family

Single person

Kinship/extended family

Other

10. Are you:(Required)

Aboriginal

Torres Strait Islander

Both

Neither

Prefer not to say

11. What country were you born in?(Required)

Australia

Other

12. Main language spoken at home(Required)

English

Other

13. Do you have a disability?(Required)

Yes

Prefer not to say

14. Your relationship to the children in your care(Required)

Mother/Step mother

Father/Step father

Grandparent

Other relative

Foster carer/guardian

Family friend

Other

Details of your children

15. Pre-birth (if you or partner are pregnant)

If you have twins add details in each row.

	Unknown	Female	Male
Pre-birth 1
Pre-birth 2

16. Child 1 (gender and age)

	Female	Male	Gender Diverse Identity
0-8 years old
9-14 years old
15-18 years old

17. Child 2 (gender and age)

	Female	Male	Gender Diverse Identity
0-8 years old
9-14 years old
15-18 years old

18. Child 3 (gender and age)

	Female	Male	Gender Diverse Identity
0-8 years old
9-14 years old
15-18 years old

19. Other children - please note their age and gender below.

Details of your children

The following information relates to the number of children in your care, their age range and gender. There are four age groups, pre-birth, 0-8, 9-14 & 15-18 years old.

20. Who referred you to the program?*(Required)

Self/Friend/relative

NGALA help line

Crisis Care

The Family Support Network

Education Institution

Childcare Centre

Health Direct

Child Protection and Family Support Services

Court referred

Hospital

Child Health Nurse

Mental Health Nurse

General Practitioner (local Doctor)

Social Worker

Parenting service

Community service

Other

Parenting Needs

21. As a parent, which of the following needs do you think relate to your child/ren?

You can choose more than one response

Behaviour

Development (ages and stages)

Drugs, alcohol and substance

Self-harm

Peer relationships

Schooling/Employment/Education

Aggression and emotional regulation

Medical condition

Mental health (Emotional stress, anxiety, depression)

Sexual health and development

Bullying

Technology and Cyber behaviour

22. As a parent, which of the following needs relate to your parent-child relationship?

You can choose more than one response

Parent-child attachment

Seeking to increase confidence

Adjustment to parenting role

Social isolation of parent

Other

23. In your community, which issues have an impact on your parenting?

You can choose more than one response

Remoteness of Support (lack of support services)

Cultural issues or racism

Crime and safety

Other

Please specify

24. If available, would you use a creche service to attend?(Required)

Yes

How many children will use the creche?

Child's age

2nd child's age

3rd child's age

4th child's age

Consent

25. I consent to the information I have provided on this form to be stored, and agree to the use of de-identified information collected for evaluation, research and/or promotional purposes by Parenting Connection WA.(Required)

Yes

26. I give permission for photographs and video of myself and/or my children to be taken used for Parenting Connection WA promotional purposes (including website, flyers, and/or social media).(Required)

Yes

27. I give permission for my details to be used to contact myself about future Parenting Connection WA sessions, courses and events or other workshops via electronic mail (email or electronic newsletter) or SMS.(Required)

Yes

1-2-3 Magic and Emotional Coaching (Mandurah)

A FREE 4-session parenting program for parents and carers of children 3 – 12 years

Multi session booking PEEL

Program details

Parent/Carer details

Family composition

Details of your children

Details of your children

Parenting Needs

Consent

Details

Venue