Client Intake Form

Child's name*

First Name Middle Name Last Name

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Birth Date

Month Day Year

Cell number*

E-mail*

Name of parent or guardian*

Medications child currently takes

Current medical and psychological diagnoses

Reason(s) for seeking services*

Does child have a history of being violent or aggressive? If so, please explain.

Are there any active court orders that affect child's interaction with either of his/her parents or interaction between parents? (Examples include but are not limited to: 1. An Order of Protection naming the child or either of the parents; 2. Court-ordered supervised parenting time / visits.)

Is there any current DCFS involvement? If yes, please explain. (This includes but is not limited to: 1. Open investigation with DCFS; 2. Current case with Intact Family Services; 3. Safety Plan in place with DCFS or any of its agents.)

Type of service requested

Theraplay therapy Three day intensive Five day intensive

Child's relationship to you:*

Child's grade in school and name of school

Names and ages of child's siblings

Availability

How were you referred or by whom?

Name of therapist you are requesting if applicable

How will you be paying? We are in network with BCBS PPO.

Will you be needing super bills?

If you will be using BCBS PPO, please provide the following information:

Member ID

Name of subscriber

Subscriber's date of birth

If you have any questions about the intake process, please contact Anna at 773/732-6179 or clinic@theraplay.org.