Art Therapy Child Intake Form

Child Information

Full Name Date of Birth Age Gender Female Male Other Prefer not to say School Grade

Parent/Guardian Information

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

Referral Information

How did you hear about us? Reason for Referral

Present Concerns

Please describe current concerns or issues

Background Information

Relevant Medical History/Diagnoses Current Medications Family Members/Living Situation

Additional Information

Goals for Art Therapy Has the child participated in therapy before? Yes No Other Comments