Child Therapeutic Play Intake

Child Therapeutic Play Intake

Submission of this form does not guarantee a booking. I review all information within two business days to ensure that therapeutic play is the most appropriate support for your child. If I feel another service would better meet your family's needs, I'll discuss this with you.
Welcome

Thank you for taking the time to complete this form. The information you share will help me prepare for our parent consultation, where we'll explore your concerns in greater depth and begin thinking together about how best to support your child. There are no right or wrong answers. If you're unsure about a question, simply answer as best you can. Estimated completion time: Approximately 10 Minutes

About Your Family
Parent/Guardian 1

First NameLast Name
Relationship
Parent/Guardian 2

First NameLast Name
Relationship
Child's Full Name
What name does your child prefer to be called?
Child's Date of Birth

MonthDayYear
Date
Home Language(s)
School / Preschool / Kindergarten
Current Grade / Year
Contact Details
Parent/Guardian 1 Email Address
example@example.com
Parent/Guardian 2 Email Address
example@example.com
Parent/Guardian 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who lives in your child's home most of the time?
Are all those holding parental responsibility in agreement with therapy?
Is there anything else you feel would be important for me to know at this stage?

Final Details

These last few questions help me ensure that therapeutic play is a safe and appropriate service for your child.
Has your child recently spoken about wanting to harm themselves or someone else?
Please briefly explain
Are there any current legal, safeguarding or custody matters that may affect therapy?
Please briefly explain.
How would you prefer me to communicate with you?
I confirm that the information I have provided is accurate to the best of my knowledge. I understand that this information will be treated confidentially and used to prepare for our parent consultation.
Signature
Date

MonthDayYear
Date
Should be Empty:

Welcome