Child Personal Details Intake Form

Child Intake Form

The information you provide on this intake form is STRICTLY CONFIDENTIAL and will not be used to inform any criminal activity. It is important that you answer the questions below honestly in order that your therapist can tailor your care appropriately. We can assure you that your therapist will not judge you based on your responses, but will use them to understand your life, and provide you the highest level of care.

When completing each section, some elements may have a (?) which means you can expand the questions to gain additional information.

Personal Details:

Parent/Guardian First Name:

Parent/Guardian Surname:

Child's First Name:

Child's Surname:

Child's Nick Name:

Child's DOB:

Child's Address:

Postcode:

Parent's Mobile Contact Number:

Parent's Home Contact Number:

Parent's Email Address:

Is it okay to: (?)

TextCallEmail

Parent's Employment Status.

Parent's Profession: (?)

What school/Uni/College does your child attend:

Child's Religion (Optional): (?)

Child's Culture (Optional): (?)

Child's Gender (Optional): (?)

Child's Sexuality (Optional): (?)

What are your Child's hobbies: (?)

Who or what are your child’s support mechanisms: (?)

Is your child safe at home?: (?)

YesNo

If no, please provide a brief description

Is your child in danger of being harmed by anyone else?

YesNo

If yes, please provide a brief description

Is your child being bullied at school or socially?

YesNo

Is your child expressing any gender/sexuality issues?

YesNo

Is your child in any kind of crisis at the moment where they may want to harm themselves or anyone else?:

YesNo

If yes, please provide a brief description

How would you describe your child’s general behaviour?

How would you describe your child’s general mood?

Select all that apply (hold ctrl on your keyboard)

Does your child regularly engage in any of the following:

Select all that apply (hold ctrl on your keyboard)

If you are currently experiencing a moment of crisis, please consider calling Breathing Space on 0800 83 85 87, the Samaritans on 116 123, Childline on 0800 1111, or NHS24 on 111 for immediate assistance. Or if you feel that there is significant risk please dial 999 and seek help from the emergency operator

Does your child have any children of their own?

YesNo

First Name:

Second Name:

Date of Birth:

Address: (please specify if different to you listed home address above)

Postcode:

School/Nursery:

Main carer: (?)

Services Involved: (?)

Does your child have any siblings?

YesNo

Is anyone else currently involve in your Child's care?: (?)

YesNo

If Yes:

Service:

Name:

Address:

Telephone Number:

Reason for involvement:

Permission to contact:

YesNo

What is your reason for seeking Therapy for your child?: (?)

What are the symptoms which lead you to seek Therapy for your child?: (?)

Does your child have any official diagnosed conditions by a medical professional?: (?)

Does your child suffer any non-diagnosed medical complaint?:

Has your child suffered any serious accidents?: (?)

YesNo

If yes, please provide a brief description

Please provide information on any of your child's past or present medication including dosage: (?)

Are you aware of your child drinking any alcohol products?:

Do you believe that your child may have a drink problem?:

Does your child drink tea/Coffee or high caffeine drinks?

Type

Unit

Quantity

Frequency

Does your child smoke?

YesNo

Type

Quantity

Frequency

Does your child take any non-prescribed or recreational drugs?

YesNo

Type

Quantity

Frequency

Has Your Child Ever Attempted to Self-Harm? (?)

YesNo

Describe If yes:

Does Your Child Currently Feel Suicidal?

YesNo

Has Your Child Ever Attempted to Complete Suicide?

YesNo

Type of Attempt

Date

Intervention Received

Does your child have any additional needs? (?)

Emergency Contact or Next of Kin: (Required Field)

Relationship:

First name:

Surname:

Address:

Postcode:

Mobile Contact Number:

Home Contact Number:

GP Details (Required Field)

GP’s Name:

GP’s Practice Name:

Address:

Postcode:

Telephone Number:

Is there any family history of psychiatric or mental health issues?:

YesNo

Please provide a brief description

We always encourage questions. If you have any specific questions which you’d like to ask about this intake form or therapy in general, please note these below, and your therapist with gladly discuss these in your initial consultation:

I confirm that the information supplied is a true and honest response to the questions asked. I understand that providing false or misleading information can interfere with the treatment provided via therapy and may delay improvements in my health. I acknowledge that this information will be held in strict confidence by Empathy Rooms Ltd, and that they will store this provided information in accordance with current GDPD laws and regulations. I give empathy rooms permission to contact me regarding this intake form to arrange a consultation and future therapy sessions. I understand that my therapist may be required to share information with my GP or other listed agencies/professionals involved in my care. For this purpose, I provide permission for my Empathy Rooms Ltd therapist to make such contact. I understand that my confidentiality will be respected at all times, but that my therapist can break confidentiality if I am at risk of harming myself; others or if there is any issues concerning child protection/welfare.

Name:

Signature:

Date: