Child Initial Questionnaire

Child's Name

Name of person completing this form

Insurance Carrier

Phone Number

Email Address

Communication Preferences

Email ok

Text ok

Voicemail ok

Who lives in the home?

What are your main concerns?

Check any of the following that apply and provide more information on the bottom of the page

There are custody arrangements for my child

My child is involved in legal issues

DCYF is involved or was in the past

My child has an IEP, 504, or special accommodations at school

Please provide details for any of the above checkmarked items

Has your child been to therapy before? What was their experience like?

As the parent, are you able and available to commit to being involved in your child’s therapy?

Is there anything else we should know?

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