Complex Care Intervention

Intake Form

Confidentiality is paramount in the Complex Care Intervention process. Your personal information shared in this intake form will be kept strictly confidential within our therapeutic team. We prioritize creating a safe and supportive environment for your child’s healing journey, and your trust in our confidentiality measures is crucial to the therapeutic relationship.

Complex Care Intervention Intake Information:

Child/Youth Full Name or Initials:

Date of Birth:

YYYY

Age:

Age at Adoption (if applicable):

Ethnicity:

Sex at birth:

Male

Female

Caregiver / Gaurdian Name:

Relationship to Child:

Address:

Address, City, Province/State, Postal Code/ZIP Code, Country

Phone Number:

Child/Youth's School:

Name of Contact Person at School:

Email of Contact Person at School:

Phone Number of Contact Person at School:

Does the Child Have Current/Past Agency Involvement?

Yes

Indentifying Information and Brief Background:

E.g. Living situation and family members

Brief Reason for Referral:

What behavioral challenges is the child/youth currently presenting?

Parent/caregiver goals for child/youth:

What changes would you like to see in your child/youth

Please List Any Medications and Past/Current Diagnoses if Applicable:

Key Strengths of the Child and Caregivers: