DPC Waitlist Sign-up

Seeds of Grace Play Therapy Expression of Interest:

We are excited to welcome you to our practice. Please fill out this form and we will contact you for a free 15 minute phone consultation. We endeavour to reach out within 48 business hours. We look forward to speaking with you soon. Thank you for your interest in play therapy with Seeds of Grace. Have a beautiful day.
Today's Date

DDMMYYYY
Parent/Carer's Full Name

Given NameSurname
Relationship to Child:
Phone Number
Format: 0000 000 000.
E-mail
example@example.com
Best Day and/or Time to Contact You
Child's Name

Given NameSurname
Child's Date of Birth
dd/mm/yyyy
I am interested in the following services (check all that apply):
Does your child have additional supports as part of their wellness team?
If yes, please provide a brief explanation below:
OT, Behaviour Support, etc..
Please provide a brief explanation regarding your reason for reaching out today (presenting concerns, challenges, hopes for therapy).
How did you hear about us?
Other
Disclaimer: Completion of this form does not secure your child a spot on the waitlist or as a client at Seeds of Grace Play Therapy. We take the safety, security and needs of our clients very seriously, and must ensure that our therapists have the knowledge and experience to best help your child. After a brief phone consultation with you, the team at Seeds of Grace will be able to make a decision if a member of the team can support your child. If not, we will assist you in finding another therapist at a different practice, who is best suited to meet your child's needs. This is in no way a reflection of severity of needs, rather an ethical measure to ensure your child is matched with the best therapist to help them grow.

NB: All information gathered from this form will remain confidential and used only as a way to contact you regarding your query.
By Submitting this form you're requesting and consent to a member of the Seeds of Grace Play Therapy team to contact you in order to discuss your needs, explain the purpose of Play Therapy and the process moving forward, as well as possible placement on the waitlist for services. Do you consent?
Should be Empty:

Seeds of Grace Play Therapy Expression of Interest: