INTAKE FORM

Biographical Information

Child - Receiving Counselling

First Name

Last Name

DOB

Parent 1

First Name

Last Name

Relationship

Phone (Mobile)

Phone (Home)

Phone (Work)

Residential Address

Suburb

Postcode

Email Address

Occupation

Parent 2

First Name

Last Name

Relationship

Phone (Mobile)

Phone (Home)

Phone (Work)

Residential Address

Suburb

Postcode

Email Address

Occupation

Significant Other 1

First Name

Last Name

Relationship

Significant Other 2

First Name

Last Name

Relationship

Child's Sibling 1

First Name

Last Name

DOB

Child's Sibling 2

First Name

Last Name

DOB

Schooling Details

Name of School

Name of Teacher

Grade Level

Teacher/School Contact Details

Referral Source

Referrer
---SelfGPPaediatricianSchoolOther

Family Doctor Contact Details

Name

Clinic

Address

Phone

Health Care

Are you the holder of a Health Care Card?
YesNo

Do you have Private Health Fund cover?
YesNo

Does your child/children have a current Mental Health Care Plan?
YesNo

If yes, 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?
YesNo

If so, please give details

Are both parents aware that services at Child’s Play Qld are being accessed?
YesNo

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?

Once you have confirmed all of the above information, please select send to submit your intake form.