WayMaker Child Therapy Referral Form

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WayMaker Child Therapy Referral Form - Parents

We use this form to gather background information about the child you are contacting us about. The details on this form give us an indication if play therapy is the right fit for your child and also help us to help you piece together what is happening for your child. After completion of this form we offer a free no obligation telephone consultation and discuss further. Your details are strictly confidential and kept in line with current GDPR guidelines. If you decide not to proceed with therapy we will delete the form. Many thanks in advance

Parent/carers full name. *

Relationship to the Child *

Your child's full name *

Date of birth *

YYYY

Gender of Child *

Male

Female

Other:

Contact Number. *

Email Address. *

Do you give permission for WayMaker Child Therapy to store your email address for further information on our services and products? *

Yes

Full Address Inc Town and Postcode *

Who lives at home with the child? *

What school does your child go to? *

What class are they in? *

Teachers name? *

What are the presenting concerns for your child? What are they struggling with on a daily basis? *

What is your child like at home? *

What is your child like in school? *

What was mum's pregnancy experience like? inc how many scans *

What was mum's birth experience like? *

Did your child experience the terrible twos? *

Did your child crawl/bum shuffle? *

Does your child suffer from motion sickness? *

Does your child like touch? i.e. acceptance of hugs *

What are your child's sleep and bedtime routine like? Does your child go to sleep on their own and stay in bed all night? *

Has anything hard happened to the family unit since your child was born even though it may have directly happened to them? e.g. illness, death, family separation, etc? *

Any history of mental health illness in your family? *

Yes

If yes please give details

What four improvements would you like to see for your child as a result of them attending play therapy sessions? e.g. reduce anger, help emotional regulation, etc. *

Please give details of any other agencies involved with your family. *

Does your child have any additional needs? *

Does your child have any allergies? *

Do you give permission for your child to have water/juice or a snack if they require during a session? *

Yes

Our sessions cost £60 per week, average number of sessions for each child is around 16. Is this something you would be able to afford? *

Section 2: Strengths and Difficulties Questionnaire

This form is our index measure which will help us understand the child's overall score for difficulties and emotional, hyperactivity, peer relationships, behaviour and social skills. We will track the changes every ten weeks.

For each item, please tick the box for no, maybe or yes. Answer all questions as best you can as you find the child at home overall in the last six months.

Considerate of other people's feelings *

Yes

Sometimes

Restless, overactive and cannot stay still for long *

Yes

Sometimes

Often complains of headaches, stomach-aches or sickness *

Yes

Sometimes

Shares readily with other children (treats, toys, pencils, etc) *

Yes

Sometimes

Often has temper tantrums or hot tempers *

Yes

Sometimes

Prefers to play alone, solitary *

Yes

Sometimes

Generally obedient, usually does what adult requests *

Yes

Sometimes

Many worries, often seems worried *

Yes

Sometimes

Helpful if someone is hurt, upset or ill *

Yes

Sometimes

Constantly fidgeting or squirming *

Yes

Sometimes

Has at least one good friend *

Yes

Sometimes

Often fights with other children or bullies them *

Yes

Sometimes

Often unhappy, downhearted or tearful *

Yes

Sometimes

Generally liked by other children *

Yes

Sometimes

Easily distracted, concentration wonders *

Yes

Sometimes

Nervous, clingy in new situations, easily looses confidence *

Yes

Sometimes

Kind to younger children *

Yes

Sometimes

Often lies and cheats *

Yes

Sometimes

Picked on or bullied by other bullies *

Yes

Sometimes

Often volunteers to help others (parents, teachers, other children) *

Yes

Sometimes

Thinks things out before acting *

Yes

Sometimes

Steals from home, school or elsewhere *

Yes

Sometimes

Gets on better with adults than with other children *

Yes

Sometimes

Many fears, easily scared *

Yes

Sometimes

Sees tasks through to the end, good attention spam *

Yes

Sometimes

Thank you for taking the time to complete this form.

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