Conifer Play Therapy | SimplePractice

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Last name

Phone

Date of birth

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Client's info

Is the client a minor?

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First name

Last name

Phone

Date of birth

Gender

Reason for care

Primary concerns for your child?

Anxiety or Depression Attentional difficulties Behavioral issues Emotional dysregulation Grief Peer conflict or Social difficulties Trauma Foster care or Adoption Divorce adjustment Autism support Suicidal thoughts or behaviors Other (please specify below)

Type(s) of support needed?

Individual Play Therapy Children's Group Therapy Care Navigation Support Parenting Education Other

Legal considerations we should be aware of?

Ex: Parenting/custody arrangements, DHS involvement, ongoing Court proceedings, etc.

Brief description of reason for seeking therapy:

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Administrative

Referral source

How did you hear about Conifer Play Therapy?

Preferred Clinician

Female Male First available

Are there other children in your household who also need support?

If Yes, please list their name(s) and age(s):

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.