Children and Young People Therapy & Wellbeing Client Form
The information provided helps sessions remain safe, supportive and appropriately tailored to your child or young person’s needs. Please answer as openly and accurately as possible so that support can feel calm, comfortable and appropriate for them.
Parent / Carer Details
Parent/ Carer Name
*
First Name
Last Name
Relationship to Young Person
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred method of contact
*
Telephone
Email
Text message
Phone Number
*
Format: (00000 000000).
E-mail
example@example.com
Child / Young Person Details
Full name
*
First Name
Last Name
How to address them
*
Preferred name
Pronouns
Date of birth
*
-
Month
-
Day
Year
Date
School / College etc if attending
*
Medical & Professional Information
Does your young person have any diagnoses or identified needs relevant to support sessions? Examples may include: - autism - ADHD - anxiety - sensory processing differences - learning needs - emotional wellbeing difficulties Please provide brief details if relevant.
*
Is your young person currently receiving support from any professionals or services? Examples may include: GP | CAMHS | School support | Counsellor | Social care | Specialist practitioner. Please provide brief details if relevant
*
GP Surgery Name
*
GP Surgery Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is your young person currently taking any medications relevant to sessions?
*
Are there any medical conditions, mental health concerns or wellbeing needs it would be important for me to be aware of?
*
Understanding Your Young Person
How would you describe your young person? Strengths, interests, personality, favourite activities etc.
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What helps your young person feel calm, comfortable or safe?
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Are there any sensory sensitivities or preferences I shouldbe aware of? Examples may include:- noise- lighting- smells- textures- movement- touch- temperature
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Are there any communication preferences that would helpsessions feel more comfortable? Examples may include:- extra processing time- direct language- reduced eye contact- structure and routine- reduced pressure to talk
*
What signs may suggest your young person is becoming overwhelmed, anxious or dysregulated?
*
Therapy & Support Focus
Please select the area that best reflects the main reason for seeking support.
*
Confidence & Social Development
Emotional Regulation & Anxiety
Sleep & Settling
Change, Loss & Life Events
Pleasebriefly describe the difficulties your young person is currently experiencing.
*
Whatwould you most like your young person to gain from support sessions?
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Safety & Wellbeing
Are there any current risks, safeguarding concerns or safetyconsiderations that it would be important for me to be aware of? Examples may include:- self-harm- suicidal thoughts- risk-taking behaviour- absconding- aggression- current safeguarding involvement
*
Parent / Carer Consent
I confirm that:- I am the parent/carer with responsibility for this young person- the information provided is accurate to the best of my knowledge- I consent to my young person attending sessions with A Gentle Pace- I understand that sessions are confidential within normal safeguarding limits- I understand that confidentiality may be broken if there are concerns regarding safety or serious risk of harm
*
I confirm the above
I understand that:- all child and teen work begins with a parent consultation- sessions are tailored to the individual needs, age and communication style of each young person- parents/carers may be asked to remain nearby or within the waiting area during sessions where appropriate- therapeutic outcomes cannot be guaranteed- I am responsible for informing A Gentle Pace of any significant changes to my young person’s health, wellbeing or medication
*
I understand the above
By submitting this form I consent to A Gentle Pace contacting me regardingappointments and therapeutic support.
*
I consent to the above
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