Child Intake Form The information you provide on this intake form is STRICTLY CONFIDENTIAL. Please enable JavaScript in your browser to complete this form.Parent/Guardian First Name:Parent/Guardian Surname:Child's First Name:Child's Surname:Child's DOB:Child's Address:Child's Town/City:Postcode:Parent's Mobile Contact Number:Parent's Home Contact Number:Parent's Email Address:Is it okay to:TextCallEmailIn order to contact you and to arrange a consultation and for future contact, please confirm the means by which we are allowed to contact you.What school/Uni/College does your child attend:What are your Child's hobbies:Golf, Swimming, Art, Music, SportsWho or what are your child’s support mechanisms:Family, Friends, School EtcHow would you describe your child’s general behaviour?Pleasant, Overactive, Obsessive Etc.How would you describe your child’s general mood?Happy, Excited, Sad, Worrier etc.Does your child regularly engage in any of the following:Playing AloneTalks about feeling stupid or worthlessTalks about feeling uglyFidgets with hands or feetCries a lot or easilySeeks attentionBites finger nailsComplains of physical problems such as headaches and stomach achesTalks excessivelyInterrupts a lot or butts inTakes risks without thinking about the dangerRefuses to follow rulesSwears a lotDoes not like being physically touchedLoses their temperBlames others a lotLies a lotStealsIs cruel to animalsFights with othersBreaks things belonging to othersRuns awaySkips schoolSets firesWets the bedHas frequent nightmaresRefuses to sleep in their own bedIs scared of the darkIf you are currently experiencing a moment of crisis, please consider calling Breathing Space on 0800 83 85 87, the Samaritans on 116 123, Childline on 0800 1111, or NHS24 on 111 for immediate assistance. Or if you feel that there is significant risk please dial 999 and seek help from the emergency operatorDoes your child have any siblings?YesNoIs anyone else currently involve in your Child's care?YesNoSocial Worker, Grandparents etc.What is your reason for seeking Therapy for your child?What are the symptoms which lead you to seek Therapy for your child?Stress, Anger, Sleep problems etc.Does your child have any official diagnosed conditions by a medical professional?Has your child suffered any serious accidents?YesNoPlease provide information on any of your child's past or present medication including dosage:Has Your Child Ever Attempted to Self-Harm?YesNoHas Your Child Ever Attempted to Complete Suicide?YesNoDoes your child have any additional needs?Emergency Contact Name or Next of Kin: (Required Field)Relationship:Address:Postcode:Mobile Contact Number:Home Contact Number:GP Details - GP Name (Required Field)GP’s Practice Name:GP Address:GP Postcode: GP Telephone Number:I acknowledge that this information will be held in strict confidence by Dynamic Diamond, and that they will store this provided information in accordance with current GDPD laws and regulations. I give Dynamic Diamond permission to contact me regarding this intake form to arrange a consultation and future therapy sessions. I understand that my therapist may be required to share information with my GP or other listed agencies/professionals involved in my care. For this purpose, I provide permission for my Dynamic Diamond therapist to make such contact. I understand that my confidentiality will be respected at all times, but that my therapist can break confidentiality if I am at risk of harming myself; others or if there is any issues concerning child protection/welfare.Name:Date:NameSubmit