Intake Form – Child CONTACT INFORMATION Email: Phone Number: PERSONAL INFORMATION for the child First Name: Last Name: Date of Birth: School Attending: Address: City: P.C.: Referred by: For minors include the following: Name of Father: Name of Mother: Name and Age of Siblings (one per line): MEDICAL INFORMATION: Practitioners/Doctors. Please include any therapeutic treatment the child is presently receiving: Medication/supplements: Medical diagnosis (inc. dates) Surgery (inc. dates) Health concerns Accidents/Trauma including emotional (include dates) Nutrition: Please track what your child eats (including snacks) over a 3 day period and send as an attachment. Also, indicate if your child is following a special diet and whether or not they have any known food allergies. THERAPIES Please indicate any therapies you have used in the past, length of time and results. Also indicate any therapies you are presently using. Past therapies: Therapies presently using: ADDITIONAL INFORMATION: Leisure time activities: Please indicate the amount of time spent on each one on a regular basis. Is there anything else you would like me to know about your child? GOALS FOR THE SESSIONS: What do you hope to gain by participating in therapy sessions? Indicate specific behavioural changes you would like to see. What concerns do you have regarding your child?