Purpose in Play Counseling Services LLC
Phone: (662) 394-8992 | Email: admin1@purposeinplaycounseling.info
Website: www.purposeinplaycounselingservices.info
Client Demographics
Child Full Name:
Date of Birth:
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Month
-
Day
Year
Date
Age:
Gender (optional):
School / Daycare:
Parent / Guardian Name:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Preferred Method of Contact:
Email
Phone
Text
Insurance Information
Insurance Name:
Insurance Policy / Member ID:
Self-Pay / Sliding Scale Inquiry
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Primary Reason for Referral (check all that apply):
Anger or emotional outbursts
Anxiety or excessive worry
Depression or sadness
Behavioral concerns (defiance, aggression, impulsivity)
Attention or hyperactivity concerns
Difficulty with peers or social skills
Grief or loss
School or academic concerns
Trauma or stressful life events
Family or parenting concerns
Sleep difficulties
Other
Briefly explain your concerns:
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Safety Concerns
Has your child ever expressed thoughts of harming themselves?
Yes
No
Has your child expressed thoughts of harming others?
Yes
No
Are there any current safety concerns we should be aware of?
Yes
No
If you answered YES to any of the above, please elaborate:
Requested Services (check all that apply):
Individual Counseling
Play Therapy
Family Counseling
Career Counseling
Unsure / Seeking Guidance
Duration of Concerns
When did you notice a change in your child's behaviors or when was the onset of the referring problem?
Current Services and Treatment History
Has your child ever received counseling or mental health services before?
Yes
No
Is your child currently receiving any services (IEP, therapy, medication, school supports, etc.)?
Yes
No
If yes, please list:
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Child Strengths and Hobbies
Briefly describe strengths of your child and/or activities/hobbies that he/she enjoys.
Consent and Acknowledgement (check both):
I confirm that the information provided is accurate to the best of my ability.
I understand that I may be contacted for additional information.
Parent / Guardian Signature (print name):
Date:
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Month
-
Day
Year
Date
Preferred Scheduled Intake Date/Time:
-
Month
-
Day
Year
Date
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