Initial intake

Welcome to Creative Therapies and your first homework assignment. These questions are a guideline in preparation for our first Parent Session. You may address the questions one at a time using bullets, writing paragraphs or by writing your child’s life story answering the questions along the way. Many parents complete the assignment together while some do separate mother/father papers. Often the mother completes this assignment and the father writes in additional information or comments where he sees particular issues differently. Please feel free to skip what’s irrelevant and add in anything else that is significant or meaningful to you. It is recommended that you work on this assignment over, at least, a few days. May this assignment be as helpful to you as to your child’s psychotherapeutic care.

Please complete and submit this form at least 24 hours prior to your scheduled appointment.

Applicant Name *
Applicant Email *

About the child

Child’s Name *

Referred by

Date of birth

Age *

Height *

Weight *

Dominant Hand *

LeftRight

Parents' detail

Mother's Name *

Mother's Age

Father's Name *

Father's Age *

Address *

Phone *

Occupation, Job Description including location and hours worked daily

Child details

Why are you seeking care for your child and why now?

First concerns

Greatest concerns

Pregnancy and birth

Developmental history including milestones, allergies and sensory concerns

Academic history including first school experiences, current school name, teacher, teaching style, relationship with your child, favorite subjects, strengths, challenges

Emotional concerns and examples

Behavioral concerns and examples including how you handle this situations

Parenting style(s), parents relationship with the child, the siblings and with each other

Sibling relationships including names, ages, birthdates and personalities

Family dynamics, concerns, home life atmosphere, responsibilities, chores

Social behavior including peer relationships. Does your child have a best friend?

Medical and psychological concerns including extended family (history and present day)

Hobbies, sports, organizations, clubs, religious attendance, successes, etc.

What is your child good at? What do you enjoy, like, love about your child?

Typical week

Chart a typical week in the life of your child include daily schedule, food intake, vitamins (brand), medication (including amount taken and when), moods, screen time details, sleep pattern (include bedtime, wakes in night, amount of sleep, where child sleeps, snoring, sleep walking, wakes up by self or requires waking, gets up easily or with great difficulty…describe). Indicate how a weekend compares to a school/camp day and any other observations between the different days, months, or seasons

Your goals for treatment

Anything else you deem important to share

Verification

Please enter any two digitsExample: 12
This box is for spam protection - <strong>please leave it blank</strong>:

Initial intake

Please complete and submit this form at least 24 hours prior to your scheduled appointment.

Initial Intake

About the child

Parents' detail

Child details

Verification

SIGN UP

READ ON

Update