Therapy Intake Form (Children) - Confidential Therapy Intake Form (Children) - Confidential To be completed by the client. Please complete the information on this form. These are some of the questions we might ask you during your first session in order to help you achieve your goals better. Completing this form accurately helps reduce the time spent on these questions during your session, so we can focus on other areas. It may seem long, but most of the questions require only a check, so it will go quickly. If you have any questions, please send us a WhatsApp message on 08096642604 and we would respond ASAP. SECTION 1: PERSONAL INFORMATION User Code (Please do not include your name). * How old are you? * What class are you? * Birthday What's your height? What's your weight? Address Gender * Emergency Contact (Name) * Emergency Contact (Number) * Emergency Contact (Email) Relationship With Emergency Contact * SECTION 2: WHY ARE YOU SEEKING HELP? Reason * Please write in details to enable us to have an idea of how to help you efficiently Give us a little history/ background * So far, how have your tried to manage the situation * What would you like to achieve with your sessions? * How would you classify your eating habit? * Poor Excellent Good How would you classify your sleep? * Excellent Good Poor SECTION 3: SUICIDE AND HOMICIDAL RISK ASSESSMENT Have you ever had feelings or thoughts that you didn't want to live? * No Maybe Yes Have you ever had the thought to kill or harm someone else? * Yes No Maybe SECTION 8: FAMILY BACKGROUND AND CHILDHOOD HISTORY How many siblings do you have and what is your position in the family? * Describe your mother and your relationship with her * Describe your father and your relationship with him * Describe your relationship with your siblings * Has anyone in your immediate family died? * No Yes Are you bullied in school? * Yes No If yes, please provide details of the bullying experience Are you bullying anyone in school? * Yes No If yes, please provide details of the bullying experience TRAUMA HISTORY Do you have ANY traumatic experiences? * Yes No If yes, please provide details (please include details if there are multiple traumatic experiences) * Is there anything else that you would like us to know? (if none, write none) * * I certify that the information provided on this form is true to the best of my knowledge * I acknowledge the use of the information provided on this form for my therapy sessions * I acknowledge that I have read and understand the informed consent (request a copy from the admin if you don't already have one) If you are human, leave this field blank. Submit Δ
