Intake form

Biographical Information
Child Receiving Counselling
Child's Name*
First Last
Child's DOB*
DD slash MM slash YYYY
Parent 1
Parent 1 - Name*
First Last
Parent 1 - Relationship*
Parent 1 - Mobile Phone*
Parent 1 - Home Phone
Parent 1 - Work Phone
Parent 1 - Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Parent 1 - Email*
Parent 1 - Occupation
Parent 2
Parent 2 - Name
First Last
Parent 2 - Relationship
Parent 2 - Mobile Phone
Parent 2 - Home Phone
Parent 2 - Work Phone
Parent 2 - Address
Street Address City State / Province / Region ZIP / Postal Code Country
Parent 2 - Email
Parent 2 - Occupation
Significant Other 1
Significant Other 1 - Name
First Last
Significant Other 1 - Relationship
Significant Other 2
Significant Other 2 - Name
First Last
Significant Other 2 - Relationship
Child's Sibling 1
Child's Sibling 1 - Name
First Last
Child's Sibling 1 - DOB
MM slash DD slash YYYY
Child's Sibling 2
Child's Sibling 2 - Name
First Last
Child's Sibling 2 - DOB
MM slash DD slash YYYY
Schooling Details
Name of School
Name of Teacher
First Last
Grade Level
Teacher/School Contact Details

Family Doctor Contact Details
Doctor's Name
First Last
Clinic
Phone
Doctor's Address
Street Address City State / Province / Region ZIP / Postal Code Country

Health Care
Are you the holder of a Health Care Card?*
- Yes
- No
Do you have Private Health Fund cover?*
- Yes
- No
Does your child/children have a current Mental Health Care Plan?*
- Yes
- No
How many sessions have you used on the plan?
List details of any allergies your child has
List details of any medical conditions or serious illnesses your child has experienced

Personal Information
Please answer these questions as best as you can on behalf of your child, to provide the psychologist some insight into your situation, prior to meeting with you.
Are there any Parenting Orders or Domestic Violence Orders in place?*
- Yes
- No
Please give details*
Are both parents aware that services at Child’s Play Qld are being accessed?*
- Yes
- No
Name of person/s who can be provided information on your child’s appointments*
What specific issues or events have occurred that have led you to counselling?*
How long have these issues been happening?*
Are you currently receiving support from any other services? Where?*
Have you sought any previous treatment for these issues? Where?*
What would you like your child to work on in therapy?*
Is there any other information that would help me better understand you and your family?
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Email
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Child Receiving Counselling