Intake Form

Childs Full Name

First NameLast Name

Date of birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Full Name of parent 1/ Guardian

First NameLast Name

Relationship to child

Full name of parent /guardian 2 if applicable

First NameLast Name

Relationship to child

contact Number

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

Email

example@example.com

Emergency Contact (this is in case of an emergency if parent(s) / carer cannot be reached during or after a session)

First NameLast Name

Emergency contact number

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

Parental Responsibility
By completing this form, you confirm that you are a parent or guardian with parental responsibility for the child listed above, and you understand that parental responsibility is required to authorise coaching sessions. In cases of dispute or when more than one individual claims parental responsibility, we may require consent from both parents. This policy ensures we are acting in the best interest of the child and maintaining legal and safeguarding responsibilities.

YesNo

Have you spoken to Tracey prior to booking this appointment?
If No, please do not book and contact Tracey directly on 07720681509 or tracey@reachforthestarscoaching.co.uk to discuss coaching needs. If Yes, please continue.

Do you have any other professionals involved in your child/teens care? e.g.social worker, CAMHS, GP, psychiatrist?

What are the key issues that you require help with?

Have any key events contributed to these feelings or behaviours?

How long have these feelings or behaviours been affecting you / your child?

Are there any situations, experiences, or events that your child finds difficult to manage?

Is there any additional information you believe I should be aware of?

Please provide the name of your child’s school, any relevant issues we should know about, and the names of any teachers or support staff who work with them

Photography and Promotional Use Consent. I give consent for photographs to be taken of my child’s work (e.g., drawings, written reflections) for use in promotional materials such as social media posts and the Reach for the Stars Coaching website. No images of my child or identifying information (e.g., names, faces) will be used. My child’s verbal consent will also be sought during sessions before any photos of their work are taken. I understand that this consent can be withdrawn at any time by contacting Tracey Harvey.

YesNo

Please be aware that I am unable to diagnose Mental Health issues. Coaching is an effective resource supporting children to identify strategies and ways forward with challenges that they are experiencing. It is not a medical service.

Name

First NameLast Name

Signature

Date