Child / Teen Intake Form

Child / Teen Intake Form
Personal Information
Child/Teen's Full Name
Age
Pronouns
Phone
Email
example@example.com
Child/Teen Home Address

Street Address

Street Address Line 2

CityState / Province

Post Code
School
Referral Source (if any)
Parent/Guardian Full Name(s) 1
EG Mother
Emergency Contact Phone Number
Parent /Guardian 1 Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Full Name(s) 2
EG Father
Emergency Contact Phone Number
Parent /Guardian 2 Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason For Seeking Counselling
Have you sought counselling services for your child/teen before?

YesNotOther
Briefly describe the concerns that brought you to seek counselling services for your child/teen.
If yes, please provide details
Current Health Status
Does your child/teen have any medical conditions, allergies or injuries that we should be aware of?

YesNoOther
If Yes, please provide details.
Has your child/teen ever been diagnosed with any mental health or neurodivergent conditions?

YesNoOther
If yes, please provide details.
Family History
Please provide information on any history of mental health/neurodivergent conditions or substance abuse in your family
Legal Information
Are there any legal, court, parenting orders, family dynamics and so on that I should be aware of, that could potentially affect your child/teen’s mental health care or wellbeing?

YesNoOther
If yes, please provide details.
What are some of your childs' assets/strengths, resources or interests?
Do you have an NDIS referral

YesNo, I am paying privatelyOther fundingOther
Consent for Treatment
I, as the parent, give consent for my child named in this document to participate in Counselling Services with Ayna Hennessy from Safe & Sound Counselling.

I understand that the Counselling Services will be provided in accordance with the laws and regulations of Australia.

I agree to pay the agreed-upon fees for these services in advance and provide consent to the terms as stated in the Cancellation and Payment Policy and the NDIS Payment Policy (if relevant).
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
NDIS Number
NDIS Plan Expiry Date

MonthDayYear
Date
Plan Manager Name
Plan Manager Email
example@example.com
Plan Manager Phone number
Support Coordinator Name
Support Coordinator Email
example@example.com
Support Coordinator Phone Number
Thank you for completing this form. The information you have provided will be kept confidential and used only for the purpose of providing counselling services to your child/teen.

Please note that in certain situations, such as if there is a risk of harm to your child/teen or others, the counsellor may be required to break confidentiality and report the situation to the appropriate authorities. If you have any questions or concerns, please feel free to discuss them with the counsellor.
NDIS Plan Start Date

MonthDayYear
Date
Should be Empty:

Child / Teen Intake Form

Personal Information

Reason For Seeking Counselling

Current Health Status

Family History

Legal Information

Consent for Treatment