Groups & Events
Groups & Events
kids Intake Form
Please fill out this information form as carefully and as thoroughly as possible. The information you provide protected as confidential information.
Date Of Birth
Postal Code (for example a1b2c5)
Please do not include phone numbers at which you do not wish to be contacted.
Current Marital Status
(Check one of the following)
Occupation of parents:
Other Family Information
Live with Child
(If Applicable) Ages
List any present health problems, major surgeries, injuries
Is your child taking any medication ?
"name of medication"
Reason for taking medication
Is there a history of mental illness in your family? If so, whom (relation) and psychological issues, if known
List any significant crises, losses or stressors
History of psychotherapy, counselling, or other treatment
Dates of treatment and issues addressed
Has your child ever experiences any type of abuse (physical, sexual or verbal)?
If so please explain:
Description of the problem
Child Strengths & Interests
Attachment Related Questions
1. Who is your child closest with? Has this changed over time?
2. What kind of baby was your child? Any complications during pregnancy/ birth? Did your child have an delays in hitting any major milestones (i.e., talking, walking)
3. Have there any long periods of separation from either parent?
4. What are your child’s relationships like with their peers?
5. What is each caregiver’s work situation (i.e., PT/FT, does one parent work away from home). How often are both parents home?
6. Describe how your child behaves when he/she is upset? Are they easily comforted and how
7. How affectionate is your child with you? The other parent?
8. Describe how your child behaves when he/she is upset? Are they easily comforted and how
9. How would you describe your Parenting/Discipline style? (please include both caregivers)
10. What pleases you most about your relationship with your child
11. What do you wish you could change about your relationship with your child
12. Are there any experiences that your child has with you or their other parent that you feel may have been a setback for him/her?