Child Art Therapy Intake Questionnaire
Child Information
Child's Name
Date of Birth
Age
Gender
School / Grade
Parent / Guardian Information
Parent/Guardian Name
Relationship to Child
Contact Number
Email
Address
Referral Information
How did you hear about our services?
Presenting Issues / Concerns
Please describe the reason for seeking art therapy for your child.
Family & Support
List of family members living at home:
Other important support people (friends, professionals, etc.):
Child's Strengths & Interests
What are your child's strengths?
What activities does your child enjoy (including art-related interests)?
Developmental & Medical History
Any significant developmental milestones or concerns?
Medical issues, diagnoses or medications (if any):
Previous Supports or Therapies
Has your child participated in any previous therapy, support groups, or interventions?
Goals & Hopes
What are your goals and hopes for your child's participation in art therapy?