Child Intake Form

This form will be reviewed with you during our first session in order to determine our best path forward

Please feel free to contact the counsellor to discuss any questions related to the intake form or Professional Service Agreement prior to your submission

This practice is not eligible to claim from medical aids. Please take note that clients are accountable to pay their own consultation fees as per the normal tariffs charged by this practice.

Date(required)

Section A.1. – Parent/ Guardian Information

All information provided herein will be protected under the confidentiality clause found in the Professional Service Agreement.

Full Legal Name(required)

Preferred Name and Pronouns (required)

I.D. Number (required)

Residential Address (required)

Phone Number (WhatsApp Capable)(required)

Alternate Number

Email(required)

Alternate emergency contact

(You will act as the client’s primary emergency contact)

Name & Pronouns(required)

Age & Relationship (required)

Number (WhatsApp)(required)

Residential Address(required)

Occupation

Employer

educatIon

I declare that i am the legal guardian of the child to be identified in the following sections of this document.(required)

Section A.2. – Client Information

Full Legal Name(required)

Preferred Name and Pronouns (required)

Age (required)

Address, if different from above

Number (WhatsApp Capable)

Email(required)

educatIon

Section B – Social System

Parental Circumstances Single Parent

Engaged

Married/ Civilly Partnered

Separated/Divorced

Joint Custody/ Separate Households

Multiple Long-term Life Partners

One Parent Estranged

Both Parents Estranged

Under Guardianship

Siblings

Pets

Close Friends

Family Members & Roommates

Name & Pronouns

Age

Relationship

Live with you (y/n)

Name & Pronouns

Age

Relationship

Live with you (y/n)

Name & Pronouns

Age

Relationship

Live with you (y/n)

Name & Pronouns

Age

Relationship

Live with you (y/n)

Name & Pronouns

Age

Relationship

Live with you (y/n)

Name & Pronouns

Age

Relationship

Live with you (y/n)

Section C – Medical Information

Doctor’s Name

Doctor’s Number

Doctor’s Address

Are you presently taking any chronic medication?(required) Yes

If so, please list

For what purpose(s)?

Are you presently taking any other medication?(required) Yes

If so, please list

For what purpose(s)?

Are you presently taking any supplements/ natural/traditional substances?(required) Yes

If so, please list

For what purpose(s)?

Please list any DIAGNOSED mental or physical conditions

Please list any SUSPECTED mental or physical conditions

Section D – Therapeutic History

If so, with whom?

For how long?

For what purpose?

Please, briefly, share your opinion on your previous therapeutic experience(s)(Did you find it to be successful? Anything you particularly liked or disliked about your therapist/the process? etc.?)

Section E – Current Situation

Please state the nature of the problem in your own words(required)

What is your most difficult relationship right now?

What is your most difficult emotion at the moment?

Please select any topics you feel you may be struggling with

Discrimination/ hate victimisation

Disability/ learning

Self-care/ responsibilities

Family/ children

Substance abuse/ addiction

Grief/ loss

Religious/ spiritual relationships

Sexuality/ gender

Sexual assault/ GBV/ abuse

Cognitive function/ concentration

Are there any special circumstances related to your childhood that you would like to note? (Adoption, separation, divorce, etc.)

Are you being raised with any particular religious/cultural/spiritual beliefs?

Any other notes you would like to add?

How did you hear about us?

Section F – Legal Particulars

I confirm that I completed this form accurately and truthfully to ensure the best possible outcome for our therapeutic relationship. Yes

Find the Professional Service Agreement here

I have read, and understand the Professional Service Agreement(required) Yes

I consent to all particulars outlined within the Professional Service Agreement(required) Yes

Find the Indemnity Form here

I have read, and understand the Indemnity Form(required) Yes

I consent to all particulars outlined within the Indemnity Form(required) Yes