Delivering free parenting events in WA
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Individual Consult Booking – GOLDFIELDS ESPERANCE
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Thank you for your interest in PCWA. To enrol in your chosen service/program, please complete the form below. Your information helps keep parenting education free for WA families.
Contact your local Parenting Coordinator
if you require any assistance.
Service Name
(Required)
Date
Time
Program details
Parent/Carer details
1. Town or Suburb you live in
(Required)
2. Postcode
(Required)
3. Full name
(Required)
First
Last
4. Preferred contact number
(Required)
5. Email
(Required)
6. Gender
(Required)
Female
Male
Gender Diverse Identity
7. Age
(Required)
Under 18 years
18 - 24 years
25 - 34 years
35 - 44 years
45 - 59 years
60 years and over
Family composition
Tell us about yourself and your family.
8. 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
Shared care/Co-parent
Other family
9. Are you Aboriginal and/or Torres Strait Islander?
(Required)
Yes
No
10. Cultural Diversity
(Required)
Culturally and Linguistically Diverse (CaLD)
(born in a country with a different cultural background to Australia, and/or speak a language other than English at home)
Born in English-speaking country
(for example: Australia, United Kingdom, United States, Canada, New Zealand, Ireland, etc)
11. Your relationship to the children in your care
(Required)
Mother
Father
Grandparent
Other relative
Foster carer/guardian
Other carer/Family friend
12. Do you have a disability?
(Required)
Yes
No
Prefer not to say
Details of your children
13. Details of your dependent children aged 0 - 18 years
Gender
Cultural Identity
Age
Actions
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child details.
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Maximum number of child details reached.
Details of your children
14. Who referred you or how did you find out about this event?
(Required)
Self/Friend/Relative
Ngala Parenting Line
Crisis Care
The Family Support Network
Educational institution
Childcare centre
Health Direct
Department of Communities (Child Protection)
Court referred
Hospital
Child Health Nurse
General Practitioner
Parenting service
Mental health service
Social Worker
Community service
Other
Parenting Needs
15. Which of the following challenges or concerns do you have about your child/ren?
You can choose more than one response
Behaviour
Aggression and emotional regulation
Development
Medical condition
Drugs, alcohol and substances
Mental health
Self and body image
Self-harm
Sexual health and development
Peer relationships
Bullying
Schooling/Employment/Education
Technology and cyber behaviour
Family and Domestic Violence
Neurodivergence
Other
Please specify
16. Which of the following best describe the challenges or needs you have in your relationship with your child as a parent/carer?
You can choose more than one response
Improve knowledge of parenting skills
Seeking to increase confidence
Fatigue/weariness
Adjustment to parenting role
Limited support for parenting role
Social isolation of parent
Parent mental health and wellbeing
Physical health or medical condition
Parent-child attachment
Parent-child communication
Family and Domestic Violence
Other
Please specify
17. Which of the following issues in your community make parenting harder for you?
You can choose more than one response
Remoteness of support (e.g. lack of support services)
Cultural issues or racism
Crime and safety
Other
Please specify
18. Creche services are NOT available at all events.
(Required)
Please only complete this question if creche has been advertised as available for this event. If you are unsure, please check with the PCWA team before responding. IF creche is available for this event, would you use the service to attend?
Yes
No
How many children will use the creche?
Please select
1
2
3
4
Child's age
2nd child's age
3rd child's age
4th child's age
Consent
19. 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
No
20. I give permission for photographs and video of myself and/or my children to be taken and used for Parenting Connection WA promotional purposes (including website, flyers, and/or social media).
(Required)
Yes
No
21. 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
No
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