Who is filling out this form?
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First Name
Last Name
Person filling this form - Email
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Person filling this form - Contact number
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Which service are you interested in?
Child's name
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First Name
Last Name
Email
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Contact phone number
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Child's age
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MM
DD
YYYY
Child's gender
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Male
Female
Other
Child's address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Therapy funding type
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Privately funded
NDIS - Self Managed
NDIS - Plan Managed
Third party funded
NDIS client number (If applicable)
Parent/Guardian/Caregiver #1 name
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First Name
Last Name
Parent/Guardian/Caregiver #2 name
First Name
Last Name
Sibling name and age
Sibling name and age
Sibling name and age
Sibling name and age
School/Kindergarten/Child Care Attending
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Current grade/year level
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Teacher's name
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Name of GP or Practice name
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Contact number
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If your child is currently seeing or has seen other allied health service providers, please select all that have been attended
For current therapies, please provide contact details and frequency of sessions
Has your child received prior counselling?
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Yes
No
If Yes, please provide the name of Company
If Yes, what was the approximate date counselling started?
If Yes, what was the approximate duration of counselling?
Does your child currently have any formal diagnosis?
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Yes
No
If Yes, please provide details regarding your child's diagnosis
What are the main areas you would like to work on for your child?
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What do you hope will happen as a result of bringing your child to Play Therapy?
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Pre-Birth History
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What was the pregnancy like? Were there any complications?
Birth History
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Delivery or any complications?
Developmental and Medical History
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Adverse experiences, illnesses and accidents?
Does your child have any allergies?
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Yes
No
If Yes, please specify
Is your child on any medication?
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Yes
No
If Yes, please specify
How does your child play?
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What are their favourite games, toys, activities?
What are your child's relationships with peers like?
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Plays with children own age, older, younger, leader, follower, loner
Social history
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Details of your child's family of origin and subsequent moves, changes and life stressors including loss of person, pets, divorce, change in school, etc
Family story - Strengths and weaknesses
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Use this space to tell us a little bit about your family and anything that you feel is important to share surrounding strengths and weaknesses
Please select your availability
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Please keep in mind that evening sessions are limited and it can be up to a 12 month wait for this time slot
Any questions or topics that you'd like to make us aware of?
