Referral Consultation Form

Please fill in the form fields below

Name*
First Surname
Email*
Phone*
Child’s/Adolescent’s name*
Child’s/Adolescent’s Age & DOB*
Class*
School*
G.P. Name*
Family Composition*
Parent’s/Carer’s Occupations*
Medical concerns/diagnosis*
Main Concerns/Symptoms & Links to Life Events*
Duration of Concerns*
Any identifiable Triggers/Patterns*
What is proving effective at managing symptoms at present*
What is exacerbating symptoms at present*
Briefly explain pregnancy and birth history for specified child above (labour, early/over-due, pain relief, first initial days after birth(temperament, sleep, feeding)*
Did your child meet all developmental milestones on time? i.e. crawling/bum shuffling, lifting oneself up, walking, speech/first words, sleep hygiene, weaning onto solids. Give some details*
What soothed your child as an infant e.g. blanket, soother/dummy, hugs*
Describe your child’s play interests/likes/dislikes from preschool age to school age to present day*
How are your child’s social skills and forming/developing and sustaining friendships?*
How is your child’s academic profile within education? – Strengths, Challenges*
How is their current health – sleep, eating, physical movement patterns*
How do they currently use coping skills e.g. breath, food, touch, talk*
Attachment Style – do they tend to seek one/both parents/carers for comfort and soothing? Do they seek or push away attachment figure at present/in the past?*
Are there any family concerns, e.g. parental separation, loss, mental health challenges or any mental health diagnosis within the family lines?*
Any other services involved with the child/family unit?*
What have you tried thus far?*
Any concerns regarding the child’s safety?*
What three goals would you have for your child/adolescent within therapy? How would you know things were improving?*
What supports have you identified that you need as a parent(s)/carers?*
Do you see any correlation with your son’s/daughter’s behaviours/presentation or symptoms in association with you or your partner’s childhood, similarities with your growth as a child/adolescent? If so, give some details please.*
How would you class and score their currently? 1-10 (Mild to Severe)*
Consent*
By completing this form you are agreeing that this information can be used for the purposes of handling your request
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