Starry Wonderland Play Therapy

Thank you for your response. ✨

Application Form

All the fields are optional unless marked as required.

Child Information

First Name(required)

Last Name(required)

Gender

Preferred Pronouns

Preferred Name if different

Date of Birth (YYYY-MM-DD)(required)

PHN(required)

Address(required)

City(required)

Province(required)

Postal Code(required)

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

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

Other Special Needs / Conditions (if any)

Other Concerns?

Have you or your child received or been receiving counselling services? If yes, please provide details.

Legal Guardian#1 Information

Guardian#1 Name(required)

Relationship to Child(required)

Phone(required)

Address if different from child

City

Province

Postal Code

Occupation

Email

Legal Guardian#2 Information (if any)

Guardian#2 Name

Relationship to Child

Phone

Address if different from child

City

Province

Postal Code

Occupation

Email

Please list all other family members in the household (if any):

Name #1

Relationship to child

Age

Name #2

Relationship to child

Age

Name #3

Relationship to child

Age

Name #4

Relationship to child

Age

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.

Fridays

10 a.m. to 12 noon 1 p.m. to 5 p.m.

Saturdays

10 a.m. to 12 noon 1 p.m. to 5 p.m.

Sundays

10 a.m. to 12 noon 1 p.m. to 5 p.m.

How did you hear about us?

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)

Δ