Intake Questionnaire – Family

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Dear Client,

Please note that all information provided in this Questionnaire will be kept strictly confidential in line with our policies outlined in “Provision of Psychological Services”

Please note that you are required to complete section A (Personal Details), whereas responses to sections B should not be completed if you feel that answering questions about your past or current situation is just too distressing. In this case DO NOT complete the questionnaire beyond section A.  If necessary, we will then discuss this together here at your first appointment.

Section C is to note your presenting concerns which will be elaborated in your intake session. Use this as a tool to assist you to articulate the concerns.

Section D is to be completed by the client child. This helps them to be involved in the process and share a little about themselves which is used in their initial appointment.

If you have any queries at all about the questions or your responses to the questions, please discuss your concerns with me.

Initial consultations are with PARENTS ONLY

Intake Questionnaire Family

This field is for validation purposes and should be left unchanged.

Child Details

Name(Required)
Address(Required)
Parents Status
Are there any current parenting orders, court orders or domestic violence orders pertaining to the child? If yes, please note below and either attach copies or email copies separately to admin@tfdservices.com.au

Parent / Guardian Details

Name(Required)
Address(Required)
Email(Required)
If Yes, please identify what applies and when it has been diagnosed (year and month)? If no, put full stop or any letter to acknowledge you have read this question.
If yes, please identify and when diagnosed (month and year).
List any medications the child is currently taking.

Section B (Parent to complete): Briefly answer the following questions:

Please complete the following sentences:

Please give short answers to the following questions.

Questions regarding your parenting

C) Presenting Issues or Concerns

Please answer the following question in only two or three sentences
Please rate on a scale from 1-10 how strongly you believe this issue is affecting you day to day (check box)(Required)
Please rate on a scale from 1-10 how strongly you believe this issue is affecting you day to day (check box)
Please rate on a scale from 1-10 how strongly you believe this issue is affecting you day to day (check box)

Final Question

Section D – Child Client to complete

Please ask the child client to answer the following questions. The child’s involvement in intervention will be determined with Sara in the initial consultation.