IMPORTANT: This form is to be complete by the parent or caregiver of the person seeking therapy.
*** PERSONAL DETAILS AND HISTORY OF CHILD
Child's name
Your name/s (Parents or caregivers)
Address
Email
Contact number
*** DECISION TO SEEK THERAPY
Are both parents in agreement of the above named child receiving therapy?
Is your child open to attending therapy of his/her own choice?
How would you describe the difficulty your child is currently experiencing? In your opinion, what do you believe is the problem?
*** 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
Please give a brief outline of your family unit ie. siblings, relationship amongst members etc.
Is there anything about your child's life (academic, social or personal) circumstances that concerns you? What worries you most? Why are you seeking therapy for him/her now? Has something changed?
Is there anything about your child's home or school situation that would be helpful for me to be aware of?
Are you aware of any other family members (close or extended) who have experienced mental or emotional health issues ie. anxiety, depression, OCD etc.
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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