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PARENTING
CHILDREN & YOUTH
GROUPS
REFLECTION SPACE
Menu
PARENTING
CHILDREN & YOUTH
GROUPS
REFLECTION SPACE
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Which program is this for?
(Required)
CFRC
UMHP SPA 1
UMHP SPA 3
Well-Being SA 1
Well-Being SA 2
Please use IBHIS ID for Parents in serviced via Well-being Centers.
Parent ID
(Required)
Parent's First Name
(Required)
Parent's Last Initial
(Required)
Parent's Email
(Required)
Facilitator Name
(Required)
First
Last
Facilitator Email
(Required)
Milestone
Building Family Strengths Interview (BFSI)
Week 5
Week 10
Week 15 (Post Survey)
Program Incentive
Program Incentive To support participation in the 15-week Parents Anonymous® groups, parents are eligible to receive gift card incentives for completing program milestones and required surveys. Each incentive is valued at $40. Gift cards are provided at the following milestones:
To support participation in the Parents Anonymous® RCT Control Groups, parents are eligible to receive gift card incentives for completing program milestones and required surveys. Each incentive is valued at $40. Gift cards are provided at the following milestones:
Milestone
Description
Building Family Strengths Interview (BFSI)
All required parent and child surveys completed
Week 5
Parent/guardian has begun group participation
Week 10
Continued participation in group sessions
Week 15 (Post Survey)
Completion of parent and child post-surveys
Milestone
Description
Building Family Strengths Interview (BFSI)
All required parent and child surveys completed
Week 5
Check-in
Week 10
Check-in
Week 15 (Post Survey)
Completion of parent and child post-surveys
Milestone
Description
Staff Initials
Date Received
Building Family Strengths Interview (BFSI)
Remember to complete all required parent and child surveys' because the facilitator will give a GC BEFORE the BFSI actually happens.
Staff Initials BFSI
Date Received BFSI
MM slash DD slash YYYY
Week 5
Parent/guardian has begun group participation
Staff Initials Week 5
Date Received Week 5
MM slash DD slash YYYY
Week 5
Check-in
Staff Initials Week 5 C
Date Received Week 5 C
MM slash DD slash YYYY
Week 10
Continued participation in group sessions
Staff Initials Week 10 Group
Date Received Week 10 Group
MM slash DD slash YYYY
Week 10
Check-in
Staff Initials Week 10 C
Date Received Week 10 C
MM slash DD slash YYYY
Week 15 (Post Survey)
Completion of parent and child post-surveys
Staff Initials Week 15
Date Received Week 15
MM slash DD slash YYYY
Participant Acknowledgment
By signing below, I acknowledge that:
I am voluntarily participating in the Parents Anonymous® groups.
I understand that gift cards are provided as participation incentives, not as payment for services.
I confirm that I have received the gift card(s) listed above on the dates indicated.
By signing below, I acknowledge that:
I am voluntarily participating in the Parents Anonymous® study as a Control Group participant.
I understand that gift cards are provided as participation incentives, not as payment for services.
I confirm that I have received the gift card(s) listed above on the dates indicated.
Parent Signature
(Required)
Date
(Required)
Month
Day
Year
Signature
(Required)
Date
(Required)
Month
Day
Year
Gift Card Serial Number (20 digits found on the back)
(Required)
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