Your Counselling Ltd.

Parent / Guardian Information Questionnaire

To be completed by a parent or guardian before their child’s intake appointment.

Please complete this questionnaire before the parent/guardian intake appointment. Brief answers are sufficient and the form should take approximately 15–20 minutes. You may leave a question blank or select “Prefer to discuss” when appropriate.

Please note the following:

There is one place where a signature is required, which you can do easily from any mobile device, tablet or computer.
Fields do not save and the form must be completed in one sitting.
Click Submit when done.

If you have any issues or questions about this form please contact our office.

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Child & Parent/Guardian Information

Child's Legal Name *

First

Last

Preferred Name

Date of Birth *

Pronouns

School / Program

Grade

Parent/Guardian 1 *

First

Last

Parent/Guardian 1 Relationship *

Parent/Guardian 1 Phone *

Parent/Guardian 1 Email *

previously or in

Parent/Guardian 2

First

Last

Parent/Guardian 2 Relationship

Parent/Guardian 2 Phone

Parent/Guardian 2 Email

Household, Guardianship & Consent

Who currently lives with your child?

Include siblings and their ages. Briefly note if your child regularly stays in another household.

Are there guardianship, parenting, custody, decision-making or court arrangements that may affect counselling?

No
Yes
Prefer to discuss

If yes, briefly describe the arrangement and identify who has legal authority to consent to counselling.

Your Child’s Strengths & Supports

What are your child’s strengths, interests and positive qualities?

What helps your child feel calm, comfortable, supported or connected?

Reasons for Seeking Counselling

What concerns led you to seek counselling for your child at this time?

When did you first notice the concerns, and has anything recently changed?

Where are the concerns most noticeable? Check all that apply.

At home
At school
With friends / peers
During transitions / change
During separation
In the community
Online / social media
Across most settings
Other

If Other, where are the concerns most noticeable?

What tends to make the concerns better or worse?

How does your child feel about attending counselling?

Comfortable / interested
Unsure
Nervous
Does not want to attend
Has not been told

What does your child understand about why they are attending counselling?

Current Areas of Concern

Please check any areas that currently concern you.

Worry / fears
Sadness / withdrawal
Anger / irritability
Emotional outbursts
Difficulty calming
Low confidence
Attention / impulsivity
Following directions / routines
Aggressive behaviour
Family conflict
Friendship / social concerns
Bullying / exclusion
School / learning
Communication difficulties
Sensory concerns
Sleep
Eating / appetite
Toileting
Significant mood / behaviour change
Social media / online concerns
Other

If Other, what other area concerns you?

Which two or three concerns are most important for the therapist to understand?

Family & Life Context

Has your child recently experienced any of the following?

Separation / divorce
Parenting or custody change
Family conflict
Illness, death or loss
Move or school change
Housing / financial stress
New household member
Bullying / peer conflict
Significant medical experience
Legal / child-welfare involvement
Frightening or traumatic event
Other
None that we are aware of

If Other, what has your child recently experienced?

Please briefly describe anything selected above that is affecting your child.

Developmental, Medical & Service History

Were there significant concerns related to pregnancy, birth or early development?

No
Yes
Unsure

e.g. speech, movement, learning, social interaction, feeding, sleep or toileting.

If yes or unsure, please briefly describe.

Does your child have a medical, developmental, learning or mental-health diagnosis?

No
Yes
Assessment in progress
Unsure

If yes or in progress, list the diagnosis or area being assessed.

Are there health conditions, allergies, medications or medical needs the therapist should know about before meeting your child?

If yes, please briefly describe.

Has your child previously received counselling, assessment or other mental-health or developmental services?

Please identify the service and anything that was particularly helpful or unhelpful.

Which professionals or services are currently involved?

Family doctor
Pediatrician
Psychologist / psychiatrist
Social worker / counsellor
Occupational / speech therapist
School support team
Other
None currently

If Other, which professionals or services are involved?

School & Social Functioning

Are there current concerns involving school?

Attendance
Learning / academics
Attention / concentration
Behaviour
School-related anxiety
Relationships with teachers
Relationships with peers
Bullying / exclusion
No current school concerns
Other

If Other, what other school concern is there?

Does your child receive school supports or accommodations?

No
Yes
Unsure

If yes, briefly describe the supports and any important social or friendship concerns.

Safety & Well-Being

Are there current concerns involving any of the following?

Self-harm or suicide-related concerns
Aggression or risk of harm to someone else
Running away or leaving safe settings
Abuse, neglect or exposure to violence
Substance use
No current safety concerns
Prefer to discuss directly with the therapist

Please briefly describe any current safety concern so the therapist can follow up.

This questionnaire is not monitored for urgent concerns. If your child or someone else is in immediate danger, call 911 or go to the nearest emergency department.

Counselling Goals & Supporting Your Child

What are the most important changes you hope counselling will support?

How will you know counselling is helping your child?

Is there anything that may help your child feel more comfortable meeting the therapist or participating in sessions?

Are there family, cultural, identity, accessibility or communication considerations that would help us support your child?

Is there anything else the therapist should know before the first appointment?

Questionnaire Completion

Completed By *

First

Last

Relationship to Child *

Date Completed *

Signature *

Clear Signature

Was this questionnaire completed with input from another parent, guardian or caregiver?

If yes, provide their name and relationship to the child.