Child Intake For ParentMuch of the information in this form helps us serve you better. Thank you for taking the time to fill it out. Please fill out only what you feel comfortable with. At the end of this form you will click on send button and the form is sent directly to email@example.com. Please be advised that all information provided is considered confidential and will not be released without your informed, voluntary, written consent.Today's Date Date Format: MM slash DD slash YYYY Child's Name* First Last Child's Date of Birth* Date Format: MM slash DD slash YYYY Child's Gender*-Gender FluidFemaleMaleTransgenderChild's Email Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code PhoneCustodial Parent A* First Last Emergency ContactCustodial Parent A Email*(Ensure email is different than the child's email) Custodial Parent A Phone*Complete if address is different than child'sCustodial Parent A Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Custodial Parent B First Last Emergency ContactCustodial Parent B Email(Ensure email is different than the child's email) Custodial Parent B PhoneComplete if address is different than child'sCustodial Parent B Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Marital StatusMarriedCommon LawSingleWidowedSeparatedDivorcedBlended FamilyCustody Arrangements if Divorced/SeparatedSole CustodyShared CustodyFosterKinshipNot establishedJointprimary residence withChild's Emergency Contact Name First Last Emergency Contact Phone NumberRelationship to ChildDo you have insurance that covers counselling?If yes, please note that we do not do third party billing. You will be responsible for paying for the session and acquiring re-imbursement from your insurance company.YesNoIf yes please specify type of professional you have coverage for Psychotherapist Registered Social Worker (RSW) Master Social Work (MSW) Other(if other, please specify)Are any of the following a concern for you? Safety/Security ViolenceIf you answered ‘yes’ to the above question, and in order to ensure your safety and security, while at Family TLC, please complete the following section.Do you have a restraining order and/or peace bond in place? If yes, with whom?Note: If you answered ‘yes’ to the above question, then you will be required to provide details to Family TLC.Please describe why Safety/Security and/or Violence is a concern.Please include the names of the professionals working with your child:Medical Professional(s):Health & Wellness Professional(s):Lawyer:Community Organization/Educational Staff:Financial Advisor:Spiritual Advisor:Other:Has your child ever received counseling before?YesNoAre there any significant events that have negatively impacted the child’s life in anyway? (Trauma’s, PTSD, Losses etc.)Is there anything you would like to tell us about the child’s ethnicity, religious beliefs and/or culture?Please describe your child’s health(include any illnesses, hospitalizations, and injuries along with the approximate dates)Does your child take any medications?YesNoIf Yes Please specify medication name, dosage, reason prescribed, side effectsDoes your child have any formal diagnosis by a physician, specialist, psychiatrist, or any other professional?Does your child have any allergies, learning disabilities, or problems in school?What is happening with your child that has prompted you to come to Family TLC? (Your core concerns)What would you like to achieve for your child by coming to Family TLC?List your child’s greatest strengths and weaknesses (preferably 3 each)Please indicate if your Child has any of the following behaviours My child is doing well in school My child reacts well to discipline My child sleeps well My child can be aggressive towards peers My child can be aggressive towards adults My child has significant friendships My child has extreme fears My child shows acts of self-harm My child argues a lot My child appears nervous My child often has physical aches or pains My child takes things that are not his/hers My child lies to avoid accountabilityHow did you hear about Family TLC? Website Brochures Third Choice Word of Mouth Directories Referrals OtherReferred by:Is there anything else you would like us to know?You are welcome to pay for your counselling by providing your credit card information in advance or give your therapist cash or cheque made out to Family TLC. How would you like to pay?debitcreditcash or chequeetransferIf credit cardName:Credit Card #:Expiry Date:Security 3 digit code on back:The cost of a one hour session range is between $140.00 and 250.00. Our office policy is 48 hours’ notice to cancel appointments. If you provide sufficient notice you will not be charged for late cancellations. If you do not provide sufficient notice you will be billed for the missed appointment.By checking this box I release the above information to Family TLC for administration purposes. All information provided is considered confidential and will not be released without your informed, voluntary, written consent.* Yes, I agree.Thank you for taking the time to complete this information. Your counselor will be reviewing this with you and will be able to expand on the information if you want. We look forward to working together with you to assist you to “find your strength”.