Sessions Intake Form
Special Needs Sessions
Who is the person to be enrolled in the sessions?
Myself
My Child
Other
Personal Information of Session Participant
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
School Name (If Applicable)
School Year (If Applicable)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Next
Your Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is your address same as the session participant?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship with the counseling person
Parent
Grandparent
Carer
Friend
Other
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Next
Referral Information
How did you hear about us?
General Practitioner
Specialist
Family or friend
Social Media
Internet Search
Other
Referrer Name
First Name
Last Name
Referral Date
-
Month
-
Day
Year
Date
Special Needs
Reason for Coaching
Autism
ADHD
Anger
Anxiety
Depression
Apraxia
Behavior Issues
Grief & Loss
Learning Difficulties
Panic Attacks
Post-Traumatic Stress
Self-Esteem
Stress
Trauma
Bullying
Other
Please identify if the participant is currently in counseling, therapies, Special Education, etc.
Please share what your goals are for participation in the special needs sessions:
Please list any Allergies
Please specify any diagnoses
Please specify any other concerns
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
Should be Empty: