Counselling Application for Children – Behind The Mirror Counselling

Chidren/Adolescent Counselling Application

Please allocate 15 minutes to fill out the form below

Date

How did you hear about my counselling services?

What brings you to see me?

Name

First

Last

Birthday

Preferred Gender

School Attending

Grade

What are your child's strengths:

Medications:

Name, Age, and residence of Siblings

Full Name of first parent:

Gender:

Age

Affiliation to Client

Complete Residential Address:

Phone Number:

Education Level:

Occupation

Relationship Status

Relationship History of past marriages/divorce:

Full Name of second parent:

Gender

Affiliation to Client:

Full House Address if different then above:

Phone Number:

Education Level:

Occupation:

Relationship Status:

Relationship History of past marriages/divorce:

If you are the guardian or adopted parent, please share information about yourself, your adoption process and any important details of the birth parents. *

Do either biological parents have a court order re: Custody /Guardianship/Access? What are the details?

ADDITIONAL IFNORMATION

Has your family lost a baby/child before birth?

If yes? When:

Have members of the family had any illness?

Any deaths/losses that your family has experienced?

Has your child experienced acute trauma?

Has your child experienced long term physical, emotional or sexual abuse?

What hobbies do members of your family have?

What would you like to be different for your family?

What would you like to be different for your child?

What do you think your child wants to be different for themselves?

What kind of parents do you believe to be?

What parenting techniques have you tried and what works?

How do you decide how to parent your child?

What happens when you do not agree?

What are the parent's strengths?

How do you think your child wants to be different in the family?

Have you tried any other resources to help your child?

How does your child feel about school?

Do they have friends?

Are they connected to any adults at school?

Does your child see the Child Youth Care worker, Counsellor, Learning Assistance, Speech and Language pathologist?

Has your child had any formal psychological or speech assessments?

Emergency Contact Person:

First

Last

Phone Number:

Relation to the Family:

Please Note re: Insurance Coverage: I am a Canadian Certified Counsellor and may be covered under your extended medical. However please check before beginning counselling to see if you do have coverage. Agreement (To be signed with Sheila Johal during Parent Intake Session) My signature confirms that I have read the above, had an opportunity to discuss it with the counsellor, and had my questions answered to my satisfaction. I also give permission for the counsellor, Sheila Johal, to contact my child’s school if necessary, and for photos and videos of my child’s work only, to be used as a teaching tool.