Intake Form

Intake Form
What is this intake for?

Autism AssessmentPlay TherapyLego Based TherapyParent Coaching
CHILD DETAILS
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender

FemaleMaleNon-BinaryTransitioningOtherPrefer not to say
Ethinicity

AustralianAboriginal/Torres Strait IslanderCaucasianBi-racialHispanic/LatinoAsianIndianOther
Primary language

EnglishSpanishChineseHinduArabicItalianGreekOther
Emergency Contact Full Name
Emergency Contact Phone Number
SCHOOL DETAILS
School Name
Grade Level
Current Teacher
Current School Counsellor
Has your child ever been retained? If Yes, please enter grade
Is your child currently on probation?
Is your child receiving special education or other services? Y/N, please explain
Does the child present any of the following issues at School? Please check all that apply

Academic problemsDiscipline problemsSocial problemsEarly language/speech problemsOther
CHILD'S HEALTH
Child's primary care doctor

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Has your child ever seen a psychiatrist?

YesNo
Is your child currently seeing a psychiatrist?

YesNo
If Yes, what is the psychiatrist's full name, address and phone number?
When was the last physical medical examination?

MonthDayYear
Date
Does your child have a physical disability?

YesNo
If Yes, please explain
Does your child have a chronic illness?

YesNo
If Yes, please explain
Does your child have a terminal illness?

YesNo
If Yes, please explain
Has your child being diagnosed with any of the following conditions?

DepressionADHDAutism Spectrum DisorderFoetal Alcohol Spectrum DisorderBorderline Personality DisorderConduct DisorderAnxiety/NervousnessBipolar DisorderSchizophreniaOppositional Defiance DisorderMood/AngerTicsInsomnia/SleeplessObsessive Compulsive DisorderAddictionsSeizuresPTSDAsthmaDizzinessSevere PMS (Pre-Menstrual Syndrome)BedwettingSevere headachesOvereatingUndereatingBone/joint/muscleHeart palpitationsShortness of breathChest painHospitalizationSleep problemsChronic illnessChronic diarrhoeaNervous stomachDisabilityNeurological problemsComplaints of ongoing tummy achePDA (Pathological Demand Avoidance)Other
Is your child currently taking any medication? Please list the diagnosis, name of medication, dosage, and name of the doctor who prescribed it
Has your child taken any medication in the past? Please list the diagnosis, name of medication, dosage, and name of the doctor who prescribed it
Is the child currently presenting any of the following behaviors?

Problems related to abuseAcademic/School problemsCurrent or past physical abuseLearning difficultiesCurrent or past sexual abuseProblems with peersCurrent or past emotional abuseProblems with teachersCurrent or past neglectSpeech problemsHistory of abandonmentSuspected sexual abuseFamily relationships concernsHistory of family domestic violenceDifficulty adjusting to family changesIntentionally hurting animalsDiscipline concernsParent/child relationship problemsMood related concernsSibling concernsDisturbing memoriesDivorce/separationDifficulty going to sleep/staying asleepReligious/Spiritual concernsNightmares/night terrorsSuicidal ideationSadness/depressionSexual identity concernsFeelings of guilt and shameInappropriate sexual behaviourExcessive worryingOvereating/refusal to eatAnxietyBedwetting or soilingAnger/irritabilityHyperactive/inattentiveFire settingRule breaking/Behaviour problemsAggression toward othersDrug/alcohol useTruancyGang involvementRunning awayStealingOther unusual behaviours or concernsNot applicable
Please add any comments you might have on the above conditions
When did you first become concerned about the main/most significant issue?
Have you attempted to deal with this issue? If so, how? Please explain
Has your child received any of the following treatments to address the concerns indicated above?

Family TherapyGroup TherapyIndividual TherapyHospitalizationNoOther
Is there a history of Trauma/Stressors related to the child?

Is there a history of Trauma/Stressors related to the child? If so, when did it start?

Rows	New born to 2 years	2 to 5 years	5 to 8 years	8 to 11 years	11 to 15 years	N/A
Chronic Illness or accident of family member
Death of significant person
Domestic violence
Family member absent
Family member emotional problems
Family member suicide
Parents divorce
Child separated from parent
Death of a pet
Difficult medical treatment
Natural disaster
Sexual assault
Family violence
Alcohol/drug/substance abuse
Criminal activity in the family

Has your child been abused? Please check all that apply

PhysicallyEmotionallySexuallyNo
Has your child been neglected? Please check all that apply

PhysicallyEmotionallySexuallyNo
MENTAL HEALTH
Has your child ever seen a Mental Health professional? (i.e a psychiatrist, psychologist, or counselor) Y/N. If Yes, we need your permission to communicate with the practitioner or agency. If No, please skip the next question and go to "Has your child ever been hospitalized for mental health concerns?"
Previous Mental Health Practitioner or Agency
Has your child ever been hospitalized for mental health concerns? If Yes, when and where?
CAREGIVER'S DETAILS
Name

First NameLast Name
What's your relationship to the child?

Biological ParentAdoptive ParentFoster ParentStep ParentGrand ParentAuntUncleBrotherSisterOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Occupation
Employer
Employment Status

Permanent Full TimePermanent Part TimeContractorCasualFixed TermUnemployedSelf EmployedOther
Education Level

Primary SchoolHigh School/Trade SchoolUndergraduateGraduateMastersPHD
Any history of emotional, learning or behavioral problems? Y/N, if Yes please explain
Any history of violence? Y/N, if Yes please explain
Any history of criminal activity? Y/N, if Yes please explain
Do you use any recreational drugs? If Yes, please list all the drugs
Are you taking any medications? If Yes, please list all medications
Do you smoke cigarettes?

YesNo
Do you drink alcohol?

YesNo
Current living arrangement

SingleSpouse/PartnerFamily of originRoommateOther
Marital Status

Never MarriedMarriedSeparatedDivorcedPartneredWidowed
What do you enjoy about this child?
What do you find most difficult about this child?
GENERAL INFORMATION - CHILD'S CURRENT HOUSEHOLD
Who does the child currently live with?

Biological parentsFoster parentsGrandparentsBiological dad & stepmomBiological mom & stepdadDad onlyMom onlySame sex coupleInstitutionRelatives
How long is this current living situation?
List your child's primary household (anyone who currently lives with the child), beginning with the oldest member - Name, Age, Gender and Relationship to you
List your child's secondary household (non-custodial or extended family, if applicable), beginning with the oldest member - Name, Age, Gender and Relationship to you
Are you currently involved in a custody dispute? Y/N, if Yes please explain
If you are separated or divorced, which best describes your relationship with your ex-spouse?

HostileFrustratingFriendlyOther
How often does the child see his/her non custodial parent?

Child's current use of electronics each week

Rows	Less than 1 hour	Between 1 and 2 hours	Between 2 and 4 hours	Between 4 and 7 hours	Over 7 hours
Computer
IPad
TV
Video Game
Phone

Is there anything I haven't asked you that you'd like to share?
REFERRAL AND PAYMENT DETAILS
How were you referred to this practice?

CounsellorPsychiatristSchool StaffCourtChild Protection StaffGPFriend/Co-WorkerAgencyInternet/GoogleSelfOther
Are you seeking services because your child is a victim of crime? If No, please skip to "Who is the Person or Agency responsible for payment arrangements with our clinic?"
Did it result in legal action? Y/N, please explain
Who is the Person or Agency responsible for payment arrangements with our clinic? Please note if you are seeing our clinic privately, payment will be required upfront before your child's appointment.
Date

MonthDayYear
Date
All referrals made by Child Protection must include:

- Current Court Order or Intake Document

- Full details of Child Protection Worker and Team Leader

Please email the above to barbarab@playfulhealingtherapy.com

Developed by Counselling Program Clinical Services, University of North Texas, Department of Counselling and Higher Education. Adapted by Jacqueline Wright, MS MFT 6.01.2009 Middleton

WI Adapted by Barbara Beirao BSW AASW 481652/Trained Child Centred and Fillial Therapist Associate Member AAPT 20190051
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Intake Form

CHILD DETAILS

SCHOOL DETAILS

CHILD'S HEALTH

MENTAL HEALTH

CAREGIVER'S DETAILS

GENERAL INFORMATION - CHILD'S CURRENT HOUSEHOLD

REFERRAL AND PAYMENT DETAILS