Child Play Therapy Referral Form
Please complete this form to refer a child for play therapy services. All information will be kept confidential.
Child’s Full Name
*
First Name
Last Name
Child’s Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Relationship to Child
*
Please Select
Mother
Father
Grandparent
Foster Parent
Legal Guardian
Other
Referring Person/Agency Name
*
Referring Person/Agency Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Referral (please describe the concerns or behaviors prompting this referral)
*
Please indicate any concerns observed (select all that apply)
*
Aggression
Anxiety
Social Withdrawal
Difficulty with Transitions
Sleep Issues
Attention/Focus Challenges
Emotional Outbursts
Other
Relevant Medical, Developmental, or Family History (optional)
Current supports or services involved (e.g., counseling, special education, speech therapy)
Signature of Parent/Guardian (required for referral processing)
*
Submit Referral
Submit Referral
Should be Empty: