IMPORTANT: This form is to be complete by the parent or caregiver of the minor seeking therapy.
*** PERSONAL DETAILS AND HISTORY OF CHILD
Your name / Parent's name
Contact (Mobile / Home / Work)
*** DECISION TO SEEK THERAPY
Are both parents in agreement of the above named child receiving therapy?
Is your child attending therapy of his/her own choice?
How would you describe the difficulty your child is experiencing? In your opinion, what do you believe is the problem?
Why are you seeking therapy for him/her now? Has something changed?
*** PAST AND CURRENT THERAPY HISTORY
What types of therapy has your child tried? How long for? And why did you stop or change?
What do you hope to achieve by sending your child to see me?
*** MEDICAL AND HEALTH CARE HISTORY
Does your child have any health problems (physical/mental/emotional)? Has he/she been admitted into hospital or care facility before? Has he/she been given a definite diagnosis? Please list all diagnosis that applies to your child now or in the past.
*** MEDICATION DETAILS
Please list all medications your child is currently taking.
*** PERSONAL AND FAMILY BACKGROUND
Is there anything about your child's schooling that concerns you?
Is there anything about your child's home situation that would be helpful for me to be aware of?
Is there anything else you think would be helpful for me to be aware of?
*** RELIGIOUS OR SPIRITUAL BACKGROUND
What religion would you say your family are practicing?
*** ADDITIONAL INFORMATION
Is there any additional information you think I should be aware of?
What is your role in the child's life? (mother/father/guardian/aunt/uncle etc.)
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