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604-614-2537
FORM
CLIENT INTAKE
Child's Information
Child's name
First
Last
Gender
M
F
Date of birth
Month
Day
Year
Age
Guardian's information
[1] Guardian's name
(Required)
First
Last
Relationship to child
(Required)
Gender
(Required)
M
F
Other
Date of birth
(Required)
Month
Day
Year
Age
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone
(Required)
Email
(Required)
[2] Guardian name
First
Last
Relationship to child
Gender
M
F
Other
Date of birth
Month
Day
Year
Age
Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Phone
Email
Status
Married
Living together
Widowed
Separated
Divorced
Single
Length of Marriage
Date of separation
Month
Day
Year
Date of divorce
Month
Day
Year
Divorced or separation arrangement: Legal Custody:
Joint
Sole
None
Physical custody
Physical custody details
Other people living in child’s home
(eg, siblings, extended family etc.)
Name
First
Last
Gender
M
F
Relationship to child
Name
First
Last
Gender
M
F
Relationship to child
Name
First
Last
Gender
M
F
Relationship to child
Name
First
Last
Gender
M
F
Relationship to child
Name
First
Last
Gender
M
F
Relationship to child
Major concerns
Please describe, in your own words, your concerns about your child and the reasons that you are seeking help.
When were these difficulties first noticed? Please explain as fully as possible.
Previous Professional Assistance (with these issues)
Agency/professional
Agency/professional
Describe any known neglect or abuse (physically or sexually) your child has experience
Medical history
Please describe your child’s general health
Please list any medication that your child currently takes and what it is for (where applicable, give the name of the prescribing physician)
Please describe any serious illnesses, accidents or injuries
Have any of your child’s blood relatives or caretakers struggled with any of the following:
ADHD
Learning disabilities
Alcohol/Drugs
OCD tendancies
Anxiety
Rage
Depression
Suicide
Relationship
Relationship
Relationship
Relationship
Relationship
Relationship
Relationship
Relationship
Childhood History
Pregnancy and birth history: (please include any information and details about any trauma, medication by mother, usual emotional strain, alcohol/durg use, complications etc.)
Please describe any major life events that your family has experiences (for example, deaths, separations, major illnesses, accidents, injuries, moves, etc)
Briefly describe your child’s behaviour at home:
Describe any special activities that the family does together:
How does your child get along with siblings:
School History
If your child is in school please answer the following questions:
Please describe your child’s academic strengths (or developmental strengths):
Please describe your child’s ability to interact socially with others (peers and/or adults)
How do school teachers and non-family members describe your child?
Additional information
What matters most to your child?
Describe your child’s strengths
What would you like to be different for your family and your child?
Are you covered under Criminal Victims Assistance Program. If yes please give your claim number and number of sessions:
Yes
No
Claim number & number of sessions
Signatures of Parent/guardian(s):
Name
(Required)
Print name
Date
(Required)
Month
Day
Year
Signature
(Required)
Name
Print name
Date
Month
Day
Year
Signature
Phone
This field is for validation purposes and should be left unchanged.
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