Starry Wonderland Play Therapy
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Application Form
All the fields are optional unless marked as required.
Child Information
First Name
(required)
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Last Name
(required)
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Gender
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Preferred Pronouns
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Preferred Name if different
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Date of Birth (YYYY-MM-DD)
(required)
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PHN
(required)
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Address
(required)
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City
(required)
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Province
(required)
Select one option
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
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Postal Code
(required)
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Diagnosed Special Needs (if any)
Autism
ADHD
FASD
Mental Health
Developmental Delay / Intellectual Disability
Learning Disabilities
Gifted
Seeking Diagnosis
Chronic Health Condition
Physically Dependent / Physical Disability
Hearing / Visual Impairment
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Reasons for seeking counselling for your child (choose the 3 most concerned)
(required)
Emotional or Behavioral Issue
Social Development / Peer Relationship
Anxiety or Depression Symptoms
Aggression and Anger Management
Developmental behavioral conditions, such as ASD, ADHD
Academic or School-related Challenges
Adjustment or Transition Difficulties
Physical Challenges
Self-esteem and Identity Issues
Traumatic Experiences
Others
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Other Special Needs / Conditions (if any)
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Other Concerns?
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Have you or your child received or been receiving counselling services? If yes, please provide details.
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Legal Guardian#1 Information
Guardian#1 Name
(required)
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Relationship to Child
(required)
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Phone
(required)
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Address if different from child
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City
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Province
Select one option
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
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Postal Code
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Occupation
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Email
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Legal Guardian#2 Information (if any)
Guardian#2 Name
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Relationship to Child
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Phone
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Address if different from child
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City
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Province
Select one option
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
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Postal Code
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Occupation
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Email
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Please list all other family members in the household (if any):
Name #1
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Relationship to child
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Age
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Name #2
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Relationship to child
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Age
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Name #3
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Relationship to child
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Age
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Name #4
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Relationship to child
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Age
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Please select your availability for the counselling session (check all that apply):
Thursdays
10 a.m. to 12 noon
1 p.m. to 5 p.m.
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Fridays
10 a.m. to 12 noon
1 p.m. to 5 p.m.
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Saturdays
10 a.m. to 12 noon
1 p.m. to 5 p.m.
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Sundays
10 a.m. to 12 noon
1 p.m. to 5 p.m.
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How did you hear about us?
Search engine (e.g. Google, Yahoo, etc.)
Recommended by a friend or colleague
Referral by a professional
Social media
Insurance provider
Online directory (Counselling BC, Psychology Today, etc.)
Event (seminar, webinar, etc.)
Blog or publication
Other
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Consent, Confidentiality & Authorization
Starry Wonderland Play Therapy respects and upholds an individual’s right to privacy. Your child’s information/application will be maintained as a confidential and secure record. If disclosure is required by law or by a court, or if Starry Wonderland Play Therapy has reasonable grounds to believe that the disclosure is necessary to prevent serious bodily harm to an identifiable person or group of persons, and in such circumstances, Starry Wonderland Play Therapy shall disclose such information as is necessary to prevent the prospective harm. By submitting your application, you hereby agree to the above, and that you have read and understood Starry wonderland play therapy’s policy on privacy and confidentiality, as well as giving us permission to email and call you. You may unsubscribe at any time.
Signature (Please Print Your Full Legal Name)
(required)
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