Child Play Therapy Intake Form
Child Information
Child's Full Name
Date of Birth
Age
Gender
Address
Parent/Guardian Information
Parent/Guardian Name
Relationship to Child
Contact Number
Email Address
Referral Information
Who referred you?
Reason for referral/concerns
Developmental & Medical History
Significant medical conditions
Current medications
Allergies
Family Information
Family members (list names and relationships)
Significant family events or stressors
Presenting Concerns
Please describe current concerns or issues for your child
When did these concerns begin?
Other professionals involved (e.g. doctors, teachers, therapists)
Goals for Therapy
What would you like your child to gain from play therapy?