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Parent’s First Name: |
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Parent’s Last Name: |
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Child’s Name: |
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Child’s Gender: |
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Child’s Age: |
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Parent’s Contact Number: |
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Emergency Contact Number: |
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Parent’s Email: |
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Parent’s Email confirm: |
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Suburb: |
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State: |
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Country: |
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Parent’s Occupation: |
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Parent’s Marital Status: |
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Siblings’ Ages: |
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Child’s Medications: |
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Does the child suffer from asthma?: |
Please bring inhalator to the session. |
Has the child ever been diagnosed with any spectrum disorder (Asperger’s, ADD, ADHD, ODD, etc) or with mental health issues (Anxiety, Depression, etc)?: |
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How well does the child sleep?: |
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Does the child use sleeping tablets?: |
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Does the child normally drink plenty of water?: |
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Child’s interests, hobbies, talents, favourite activities, strengths: |
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Child’s pets, favourite animals: |
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Child’s favourite colour: |
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What is the problem you want to solve by coming to therapy? |
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How would you like the child to feel/behave/see things at the end of successful therapy? What would you like to achieve? |
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Any other important background about the child’s history, etc? |
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After therapy I offer a free follow up. What is your preferred method of follow up/feedback? |
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How did you find me? |
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Private Health Fund?: |
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Can I add you to my mailing list for updates? |
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Terms and Conditions |
Please read carefully |
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