Activity and Play Therapy - Client Intake Form
Confidential Information - To be completed by parent, guardian (if under 18) or client (if over 18)
Section 1 - CLIENT INFORMATION
Name
First Name
Last Name
Preferred Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Male
Female
Non-binary
Prefer not to say
Other
Cultural background / Ethnicity
Primary Language
Interpreter Required?
Yes
No
NDIS Participant?
Yes
No
If yes, NDIS number:
Plan Manager (if applicable)
Support Co-ordinator (if applicable)
Section 2 - PARENT/ GUARDIAN / PRIMARY CARER INFORMATION
Name
First Name
Last Name
Relationship to the Child
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alternate Emergency Contact Name
First Name
Last Name
Alternative Emergency Phone Number
-
Area Code
Phone Number
Relationship to Child
SECTION 3 - REFERRAL INFORMATION
How did you hear about Activity and Play Therapy?
Self-Referred
School
GP
Support Co-ordiator
Department for Child Protection
Other
Reasons for Referral/ Primary Concern
Current or Past Diagnoses (if applicable)
Any history of Trauma, Parent Separation, Grief, Loss or significant life changes?
Yes
No
If yes, explain briefly
SECTION 4 - GOALS FOR THERAPY
What would you like to achieve from Activity and Play Therapy?
Emotional Regulation
Social Skills Development
Behavioural Support
Trauma Informed Care
Sensory Processing
Support with anxiety/ depression
School Transition or challenges
Building Self esteem/ confidence
Other
SECTION 5 - PROFESSIONAL INVOLVEMENT
Please list any other professionals or Services currently involved (e.g., OT, Speech, Psychologist, School Counsellor):
SECTION 6 - MEDICAL INFORMATION
GP Name
Clinic Name
Phone Number
-
Area Code
Phone Number
Allergies/ Medical Conditions
Current Medications
SECTION 7 - PERMISSIONS AND CONSENTS
I consent to my child receiving Activity and Play Therapy
I give permission for the therapist to contactrelevant professionals involved in my child’s care (e.g., school, GP, othertherapists) where appropriate.
I understand that information shared is confidential unless there is a risk of harm to the child or others.
Name of Parent/ Guardian
First Name
Last Name
Date
-
Day
-
Month
Year
Date
SECTION 8 - ADDITIONAL INFORMATION
Is there anything else you would like your therapist to know?
Submit
Should be Empty: