Child Development History

This intake questionnaire will help me get to know your child, and what brings you to therapy.

Please complete and return before your first visit.

Child's Name

Date of Birth

Age

Parent/Carer name

Relationship to this child

Address

Preferred Phone

What are your main concerns about your child?

Siblings / step-siblings and their ages

Current Medications

Current Medical Concerns / any diagnoses?

Is your child currently seeing another counsellor, psychologist or psychotherapist, or have they seen someone in the past?

Maternal stress levels during pregnancy?

Any family stress, shocks or overwhelming experiences during your child's first 7 years?

Milestones in first 12 months - early, late, generally on target (rolling, tummy creeping, crawling, walking)

How would you describe your child - easygoing, stressed, sensitive, restless, happy, gentle, creative, stresses easily, easily overwhelmed?

Age starting childcare

Age starting school?

Mood after school

Angry, restless Anxious, shutdown Talkative, happy Exhausted, tired, moody

Favourite games, hobbies, interests, story book characters?

Any favourite sporting (or other) heroes?

Plays alone, socialises easily, makes friends easily, loves company, loves playing outside?

Exposure to television, digital devices, smart phone - hours per day?

Describe your child's behaviour when stressed - tantrums, acts out, withdraws, shuts down?

What are your child's special gifts and talents?

What is it about your child that delights you the most?

Why are you here? What would you like to achieve from these counselling sessions?

Contact Information