Survey | Azita Attachment School

Parent(s) full name *

Mobile number (the one with WhatsApp) *

Mobile number (the one with Telegram) *

Email *

Country of residence *

Number of children *

Age (of the child this is about) *

Gender (of the child this is about) *

Girl Boy

Does your child have a specific psychiatric diagnosis? *

Yes No

If your child has a specific diagnosis, please describe it

What is the main concern or problem that made you seek coaching? (2–3 lines)

What have you done about this so far? *

Previous therapy/counseling Reading books or taking a course Other