Child Intake Form

Please complete all sections as thoroughly as possible. This information helps us provide the best care for your child.

Basic Information

Child's Name *

Child's Date of Birth

Parent(s) Name(s) *

Child's Address

Parent(s) Address (if different)

Parent(s) Occupation(s)

Gender

First Language

School Information

School and Class

Teacher's Name

Family & Household Information

Family Composition (including siblings names and ages)

Household Composition (if different to family)

Person completing this form and relationship to child *

Concerns & History

Reasons for concern (include duration of problems) *

Please include any feedback from other support providers including childcare, school etc.

Developmental History

Include details of pregnancy, birth, developmental milestones, health/medical, separations/losses, personality as an infant, significant life events that have been difficult/beneficial

Child's Current Circumstances

Include any recent or upcoming major life changes, significant family problems/issues, medical issues or medication, school, eating problems, sleeping pattern, emotional state, relationships with peers, siblings, parents, behaviour, strengths, talents, interests...

Family History

Including structure, medical, psychiatric, addictions, parents family/personal histories, parental relationship etc.

Strengths & Relationships

What are the child's interests, hobbies, talents and strengths?

How are the child's peer relationships?

Does he/she prefer to play alone, with 1 special friend or in a group? Does he/she host/get invited to parties and playdates?

How do you connect with the child?

Describe how/if you play, when you play, whether play is easy for you? Were you played with as a child?

Goals & Assessment

How would you know if things were getting better?

What specific changes would you like to see?

Has your child ever been assessed for any type of neurodivergence?

e.g. ADHD, Autism, dyslexia, OCD etc.

How is your self-care? How do you take care of yourself as a parent?

Consider sleep, diet, exercise, time out, hobbies, etc.

Additional Information

Any other relevant information

Significant events, other services involved, who is the child most attached to, who do they seek out if upset?

Signature

Date

Digital Signature (Full Name) *

By submitting this form, you consent to the collection and use of this information for therapeutic purposes. All information provided will be kept confidential and used solely for providing appropriate care.