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CONTACT S. Wendy Kritzer
CHILD & TEEN THERAPY INTAKE FORM
This online form is intended for Children and Teens.
About you
*
Indicates required field
Name of person completing this form:
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First
Last
Phone Number
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Email
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Your relationship to the child:
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Other parent/legal guardian
Name of other parent/legal guardian:
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First
Last
Phone Number
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Email
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About the child/teen
Child's name
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First
Last
Childs age
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Child's date of birth (MM/DD/YYYY)
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Please enter the month, day, and year of the child's birth.
Home Address
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Who does the child live with?
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Parents are currently
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Other
Married
Seperated
Divorced
Common law
Name of child's school
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Grade
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PRE-K
1
2
3
4
5
6
7
8
9
10
11
12
Reason for your child's visit
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Medical history
Has your child been diagnosed with any conditions
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Please list any medications your child currently takes
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Please tell me about any other mental health professionals your child has consulted with in the past
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approximate dates, type of professional seen, reason for the consultation, nature of the treatment, outcome of the treatment.
Please list any family history of mental illness
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What are your goals for counselling
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Symptoms List
*Parents, if possible, please allow your child to complete this portion. If your child is too young, complete symptom check list from your observations of your child.
Please check all symptoms that apply (Part 1)
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Headaches
Memory problems
Depression Sleep problems
Heart palpitations
Feeling tense or nervous
Academic concerns
Ideas of harming yourself
Drug use
Worries about money
Feeling shy around others
Not confident
Having a lack of friends
Stomach problems
Concerned about eating habits
Feelings of panic, fear, phobias
Trouble concentrating
Alcohol use
Feeling sad or depressed
Grief or loss
Symptoms (Part 2)
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Nightmares
Feeling restless
Feelings of hopelessness
Feelings of worthlessness
Low self-esteem
Disturbing thoughts
Hallucinations
Aggression
Mood swings
Recurring thoughts
Chest pain
Suicidal thoughts
Trembling
Sexual concerns
Sexual identity concerns
Anger
Ideas of harming others
Memory problems
Chronic pain
Blaming or criticizing self
Symptoms (Part 3)
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Abusing others
Dizziness
Feeling tired
Feeling a need to be on the go
Problems at home
Anxiety
Antisocial or illegal behavior
Concerned about family members
Irritability
Abused by others
Sick often
Isolating self
Disorganized thoughts
Relationship problems
Distractibility
Impulsive
Poor judgment
Please add any other information about your child that would be helpful for the counselor to know
*
AGREEMENT FOR PARENTS OF MINOR CHILDREN
Counselling can be a very important resource for children. Establishing a therapeutic alliance outside of the home can:
• Facilitate open and appropriate expression of strong feelings such as guilt, grief, sadness and anger.
• Provide an emotionally neutral setting in which children can explore these feelings.
• Help children understand, accept, and cope with whatever difficulty they may be experiencing.
• Offer feedback and recommendations to a child’s caregivers based on knowledge of the child’s specific emotional needs and developmental capacities.
However
, the usefulness of therapy may be limited when the therapy itself becomes simply another matter of dispute between parent and child or between parents. With this in mind, and in order to best help your child, I strongly recommend that your child and each of the child’s caregivers (e.g., parents or stepparents) mutually accept the following as requisites to participation in therapy.
1.
As your child’s counsellor, it is my primary responsibility to respond to your child’s emotional needs. This includes, but is not limited to, contact with your child and each of his or her caregivers, and gathering information relevant to understanding your child’s welfare and circumstances as perceived by important others (e.g., paediatrician, teachers). In some cases, this may include a recommendation that you consult with a physician, should matters of your child’s physical health be relevant to this therapy.
2.
I ask that all caregivers remain in frequent communication regarding this child’s welfare and emotional well-being. Open communication about his or her emotional state and behavior is critical. In this regard, I invite each of you to initiate frequent and open exchange with me as your child’s therapist.
3.
I ask that caregivers recognize and, as necessary, reaffirm to the child, that I am the child’s helper. This may include encouragement for the child that is reluctant or anxious about therapy, or support and optimism regarding change. Also, I have found that use of therapy as a consequence or punishment is usually not helpful.
4.
This counselling Will Not yield recommendations about custody, nor do I provide reports
The Client/Parent agrees:
1. To provide prior notice of 24 hours if canceling an appointment. (Voicemail can be left anytime) Failure to provide proper notice may result in a personal charge for the late cancellation. Your prompt cancellation will permit someone else to the time and thus reduce the waiting periods for others;
2. To pay the Therapist’s fees at end of each session. If you are using an Employee Assistance Plan or Insurance Policy, you are responsible for paying the full fee and submitting your claim personally. It is the Client’s responsibility to ensure your Therapist meets the criteria for your specific Employee Assistance Plan or Insurance Policy. Neither the therapist nor The Counselling Corner is responsible for denied claims.
3. If you subpoena your therapist or anyone from The Counselling Corner, costs for court preparation, client rescheduling and court appearance(s) will be paid by the client/parent at a rate of $180 per hour.
The Therapist agrees:
1. To provide counselling assistance based upon the Client’s/Parent's goals.
2. To maintain the confidentiality of the Client, unless:
a) He/she may be a danger to yourself or others, or there is a reasonable suspicion of child abuse or neglect. You recognize in such circumstances that I have a legal and ethical responsibility to my professional association to notify the proper authorities.
b) It is appropriate to consult with a professional colleague to improve the quality of my service to you ; the information shared with this professional colleague will be kept anonymous and is restricted to the information necessary to aide in meeting your desired goals and to assist me in providing adequate service. This colleague will also be held to the rules of confidentiality.
c) You initiate a legal action whereupon I may use information from my records to defend myself.
By typing your name in this field you agree to your duties as the "Client", Identified in the paragraphs above.
*
Please write your name
S. WENDY KRITZER has agreed to their duties as the "Therapist", identified in the paragraphs above.
by clicking "submit" the client agrees to share the information entered throughout this form with S. WENDY KRITZER
.
signatures will be gathered upon the initial appointment.
Submit
Home
Find your counsellor
Saskatoon
Martensville
Regina
Canwood / Prince Albert
Swift Current
Warman
Humboldt
Nipawin
Moose Jaw
Estevan
Biggar
Rates
Intake Forms
Child & Teen Intake forms
Adult Intake form
Digital Consent Form
Join our team