Application Form

1. Child Information

2. Family and Contact Information

Address:

3. Health and Development Information

Social and Emotional Development Information:

4. Counseling and Rehabilitation Request

Reason for Application and Main Issues: Goals and Expectations: Requested Support and Therapy Types: Individual EducationBehavior TherapyPlay TherapyChild and Adolescent CounselingFamily TherapySpecial Education and Development ProgramsPsychological CounselingOther Other (please specify): Additional Notes or Special Requests:

5. Consent and Privacy

I confirm that the information provided is accurate and may be used in accordance with privacy policies.
This information can be shared with the child counselor and relevant education/therapy teams.