Inquire about Play Therapy & Counseling

Child's First Name

Child's Last Name

Child's Birthday

Month

Day

Year

Child's Curent Grade Level

Child's CurrentGrade Level

Parent Last Name

Parent Email

Parent Phone Number

Please briefly describe why you are seeking counseling/play therapy for your child

What specific concerns or behaviors have you noticed?

How long have these concerns been present?

Has your child previously received counseling or therapy?

Yes

No

If yes, please explain

Current areas of concern for your child (Check all that apply):

Any additional concerns, please list them here

Does your child have any diagnosed conditions?

Yes

No

If yes, what conditions?

Who diagnosed these conditions?

Current medications and/or allergies if applicable. If none, put N/A

Will be using Insurance?

Yes

No

Primary Insurance Provider

Policy Number- If self pay, put 0

Name of Policy Holder

Please upload the front & back of your insurance card if applicable

I consent for my child to receive play therapy/counseling services through The Kid Connection.

I understand that confidentiality will be maintained in accordance with state laws, with exceptions related to safety and mandated reporting.

I agree to attend parent consultations as needed to support my child’s progress.

Parent/Guardian Signature

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Play Therapy & Counseling