Wellington - New Client Form
Date
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Day
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Month
Year
Date
1. Client / Contact Details
Parent / Carer Name:
Phone:
Email:
example@example.com
Address:
Preferred contact method:
Phone
Email
2. Referral Source
How did you hear about us?
Website
Social Media
Referral (please specify from who in the 'other' section)
Other
3. Client Profile (person receiving the support)
Child / Client Name:
Date of Birth
-
Day
-
Month
Year
Date
Gender:
Male
Female
Other
Diagnosis / Medical Information (if known):
Current school / workplace / program (if applicable):
Key strengths / interests:
Key challenges / support needs:
4. Reason for Enquiry
Main reason for contacting us:
What areas would you like support with?
Emotional Regulation
Life Skills
Social / Friendship Skills
Other
5. Current Support
Are you receiving current support?
Yes
No
If yes, who / what type:
Ongoing therapy / interventions?
Yes
No
If yes, details
6. Logistics & Scheduling
Preferred days / times for assessment:
Special requirements or considerations for the parent/carer at consultation:
Sensory
Accessibility
Other
Submit
Should be Empty: