Child Play Therapy Consent and Intake Form

Child Information

Child's Full Name Date of Birth Age Gender

Parent/Guardian Information

Parent/Guardian Name Relationship to Child Phone Number Email Address Address

Reason for Referral

Please describe the concerns leading to seeking play therapy:

Medical and Developmental History

Relevant medical history, diagnoses, or developmental concerns: Current Medications

Family Information

Please list household members and relationship to child:

School Information

School Name Grade Academic/Behavioral Concerns

Consent for Play Therapy

Please check to indicate your consent:

I give consent for my child to participate in play therapy sessions. I consent to necessary communication between therapist and relevant persons (e.g., teachers, doctors). I understand that confidentiality may be broken in the case of emergencies or when required by law.

Signature

Parent/Guardian Name (Signature) Date