DPC Waitlist Sign-up

Today's Date*

DDMMYYYY

Parent/Carer's Full Name*

Given NameSurname

Relationship to Child:*

Phone Number*

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?*

YesNoNot Sure

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?*

Yes

Seeds of Grace Play Therapy Expression of Interest: