Child Intake Form

Confidential Child Intake Information

As part of the initial intake and assessment process, we would like you to complete the attached questions. This will provide us with an overview of your child’s development and challenges thus far.

You might not know all the answers, that is okay. Also, you are certainly free to choose not to answer any questions if you would like that to remain private. Keep in mind that the purpose of all the information in these forms is to help you and your child address the current challenges in the best possible ways.

Once you have completed the questions, your psychologist will review the information with you and there is enough opportunity to further discuss things, if you wish to do so.

Child's Name*

Child's Date of Birth*

Child's Age*

Name of Child's Mother

Phone Number of Child's Mother

Name of Child's Father

Phone Number of Child's Father

Name of person completing this form and relationship to child*

Who is likely to bring the child to the session(s)

Are both parents aware that your child is attending a psychologist

Yes

Parents of child separated or divorced

Yes

If separated/divorced, since when

If separated/divorced, are there any stepparents/guardians

Please list all the people currently living in the child's household

If any siblings are living outside the home, please provide their names and ages

If your child also lives with another parent/carer, are there any Custody Orders

Yes

If yes, you will be required to bring in a copy of these orders at your first sessions, for us to keep on file. Also, in the event of shared legal custody, both parents will need to provide authorization for the child to attend sessions.

If your child also lives with another parent/carer, please provide the current arrangements

Which (pre)school does your child attend

At school, which grade is your child currently in

Contact person from school

Role of school contact person

Phone number of school contact

Email of school contact

Has your child previously been diagnosed with any psychological disorder, learning disorder, a medical condition or illness? If yes, please provide details

Does your child currently take medication? If yes, please provide details

Are there currently any other professionals involved with your child? If yes, please provide details

What is the main reason for your child to see a psychologist? Please describe the current issues

Have you told your child that they will be seeing a psychologist and if yes, what have you told them?

What are your child’s hobbies/interests/strengths and any other information you would like to share with us before attending the first session

Confidential Child Intake Information

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