5 minutes to complete
To complete the Child Therapy Intake Form, individuals must be legal guardians or parents of the child seeking therapy services. They must also be willing and able to provide accurate and detailed information about the child's medical history, behavioral concerns, and any other relevant information requested on the form.
Child’s Full Name
Date of Birth
Gender
Preferred Pronouns
Parent/Guardian Name(s)
Contact Phone Number
Email Address
What concerns or challenges led you to seek therapy for your child?
Has your child been diagnosed with any medical, developmental, or mental health condition? If yes, please specify.
Please list any current medications the child is taking.
Has your child received therapy or counseling before? If yes, please describe.
Who lives in the child’s household? (e.g., parents, siblings, others)
How does your child get along with family members and peers?
What are your child’s strengths, interests, or hobbies?
What are your goals or hopes for your child’s therapy?
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