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
Significant Other 1
First Name Last Name Relationship
Significant Other 2
Child's Sibling 1
Child's Sibling 2
Schooling Details
Name of School Name of Teacher Grade Level Teacher/School Contact Details
Referrer ---SelfGPPaediatricianSchoolOther
Name Clinic Address Phone
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
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.