Request for Intake Appointment

Name of person completing the form

First NameLast Name

Name of the child/client you are interested in seeking support for:

First NameLast Name

Age(s) of identified client(s)

Your relationship to client(s):

(i.e Mother, Father, Step-parent, Other family member or significant person, Professional, Adopted parent/s, Foster Carer.)

Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Best time to contact you and discuss support:

SMSPhoneEmail

Preferred email:

example@example.com

Are you familiar with the Play Therapy Modality or do you feel you need a little more information? :)

What is your motivation for seeking Play Therapy at this time?

Is your child or child in your care, currently engaging with additional support services, or accessing interventions (OT, Speech, Psychology, medical)?

(This may include interventions such as OT, SP, Peadiatrition, Behavioural Support in some form)

Has your child/or client had any previous experiences of interventions and/or therapy?

(This may include interventions such as OT, SP, Peadiatrition, Behavioural Support in some form)

Does the child/client have a current diagnosis or undergoing current assessment (if applicable)?

How did you hear about our services at The Play Therapy Studio?

Any additional information (or questions you may have) that may help us support you and your family.