Child Life Therapy

Client Intake Form

Please complete this form to help us get to know your child and tailor therapy to their needs. There are no wrong answers — this is a safe, supportive space.

👶 Child Details

Full Name

Preferred Name

Pronouns

He/Him She/Her They/Them Other:

Date of Birth

School/Setting

Grade/Year

🧠 Neurodevelopmental & Medical Information

Does your child have a current or suspected diagnosis? (Tick all that apply)

ASD ADHD Sensory Processing Differences Anxiety Trauma history Developmental delay Learning differences

Other:

Are there any relevant medical needs or safety concerns we should be aware of?

Yes: No

💬 Communication Style

How does your child usually communicate?

Verbal (full sentences) Verbal (limited speech) Gestures or facial expressions AAC device / communication book

Other:

Does your child understand instructions or new concepts best when:

Shown visually Explained verbally Through demonstration/play With repetition and support

🌈 Strengths & Interests

What does your child enjoy?

Drawing or crafts Music or singing Movement or active play Building or puzzles Pretend play Animals or nature Technology or screens

Specific interests/special topics:

What are your child's superpowers? (e.g., kind heart, memory, sense of humour)

⚡ Challenges or Triggers

What situations might your child find difficult?

Transitions / changes to routine Loud or crowded environments Unexpected touch or noise Waiting or turn-taking Emotional outbursts Social interactions Medical settings or anxiety Separation from caregiver

Other:

What helps soothe or regulate your child?

🎯 Goals for Therapy

What would you most like support with? (Tick all that apply)

Emotional regulation Confidence and self-esteem Understanding and expressing feelings Social skills / peer interactions School transitions or engagement Coping with medical experiences Reducing anxiety or overwhelm Supporting identity and neurodivergent pride Helping our family understand and support them

Other:

📞 Parent/Carer Contact Information

Full Name

Phone Number

Child Life Therapy

Specialized therapy services for children with ASD, ADHD, and trauma backgrounds.

Contact

Newcastle, NSW 2282
Australia

+61 438 265 648

hello@childlifetherapy.com.au

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