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Child Therapy Intake

For a parent or guardian to complete. If your child is at immediate risk, please contact emergency services or your doctor rather than waiting for a reply.

Child's name* (required)Date of birth* (required)Your name* (required)Your relationship to the child* (required)Email address* (required)Phone number* (required)Address

What's happening

What are you most concerned about?* (required)

Anxiety Low mood Anger or behaviour School refusal Friendships Sleep Eating Bereavement Family separation Trauma Neurodiversity Self-harm

Tell us what you've noticed* (required)How long has it been going on?* (required)Did anything happen around the time it started?

About your child

School and year groupDoes school know?* (required)

Is any support already in place?* (required)

School counselling SENCO involvement An EHCP or support plan CAMHS or equivalent Paediatrician Speech and language None

What is your child good at, or does she or he enjoy?* (required)Who's at home?* (required)

Health and safety

Medical conditions and medicationHas your child ever harmed themselves or talked about not wanting to be here?* (required)Is there any current involvement from social services?* (required)

Consent

Do you hold parental responsibility?* (required)Does the other parent know about this referral?* (required)Does your child know about the referral?* (required)What have you told your child about coming?* (required)

I consent to my child receiving an assessment* (required)

Leave this field empty