Child Counselling Intake formIf you have connected with me already and we’ve booked your child in for a session, please fill out the intake form below before our first session. Child's Name * First Name Last Name Child's Date of Birth * MM DD YYYY Child's age * Area/city the child resides * School and grade attending * What brings you to see me? * How did you hear about me? Has your child ever experienced any long term physical, emotional abuse or neglect? * Does your child take any prescription medication? * Yes No Name of medication, dosage, frequency and use? Has your child had any major illness, been hospitalized, or undergone any intrusive medical procedures? * Has your child ever received a professional diagnosis such as ADHD, autism, learning disability, anxiety, depression, etc.? If so, what have they been diagnosed with? * Please briefly describe any significant or stressful life events that your child has been experiencing. * If your child is in school, how are they doing? * Name of 1st parent/caregiver * First Name Last Name Relationship to 1st parent/caregiver * Phone number of 1st parent/caregiver * (###) ### #### Email address of 1st parent/caregiver * Occupation and education level of 1st parent/caregiver * Name of 2nd parent/caregiver First Name Last Name Relationship to 2nd parent/caregiver Phone number of 2nd parent/caregiver (###) ### #### Email address of 2nd parent/caregiver Occupation and education level of 2nd parent/caregiver Marital status of the Child’s parents * Hobbies/activities of the child and family * Was the pregnancy planned for this child? Were there any stresses or health concerns during the pregnancy, birth, or first two years? * Has your family lost a baby/child before birth? * Yes No Siblings/other family/whom does the child live with? * Have there ever been changes in whom they live with? * What deaths/losses has the family had? * Are there any court orders in place regarding parenting for this child? * What are the ethnic backgrounds of the family? * Any religious affiliation in the family? * Do you have a family physician? * Yes No If you do have a family physician, please provide name(s) and telephone number(s) What would you like to be different for your family? * What kind of parents do you believe to be? * What parenting techniques have you tried and what works? * What parenting books/courses have you engaged in? * How do you decide how to parent your child? What happens when you do not agree? * What would you like to be different for your child? What do you think your child wants to be different for themselves? * How do you think your child wants to be different in the family? * What are your child’s strengths? * Do you have any assessments of your child to share? * Do you have insurance for counselling sessions? * Do Tuesdays afternoon/evenings work for counselling sessions? * Yes No Possibly By typing my name below, I confirm that I have completed this application to the best of my ability and have fully read all the statements listed above. I acknowledge that the information I provide in the application is true and accurate. * I also give permission for the counsellor to contact my child’s school, and for photos and videos of my child’s session to be taken solely for the educational/learning purposes of the therapist. By typing my name below, I confirm that I have completed this application to the best of my ability and have fully read all the statements listed above. I acknowledge that the information I provide in the application is true and accurate. I also give permission for the counsellor to contact my child’s school, and for photos and videos of my child’s session to be taken solely for the educational/learning purposes of the therapist. Thank you!
