Child's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Caregiver A - Name *

First Name

Last Name

Caregiver A - Phone *

(###)

###

####

Caregiver B - Name

First Name

Last Name

Caregiver B - Phone

(###)

###

####

Is the child a returning client?

Yes

No

Child's Counselling Needs

Tick any that apply

Abuse

Anger

Anxiety

Bullying

Coping with Change

Compulsive Behavior

Depression

Eating Issues

Emotional Regulation

Family Issues

Grief and Loss

Head Injury

Identity

Medical/Health

Parental Separation

School Issues

Self-Harm

Sensory Issues

Social Anxiety/Issues

Substance Abuse

Suicidal Language

Trauma

Other (please outline below)