Play Therapy with Secure Foundations

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Thank you for your interest in play therapy. This form is designed to gather information that will help us understand your needs and is the first step in ensuring we're a good therapeutic fit.

Instructions:

Please take a few moments to provide responses to the following questions. Your input will assist us in determining if we are a good match for your unique circumstances and goals. All information shared is confidential and will be used solely for the purpose of information gathering. Once you have completed this form we will be in touch to provide further information or offer you an intake appointment.

Name of parents *

Email address *

Phone number *

Name and DOB of child *

Any other therapeutic support involved?

Yes

Clear selection

If yes, please advise *

Current challenges?

Have you been involved in therapy previously?

Goals of therapy?

Submit

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