Lisa Gagnon Counselling
Individual, Child and Family Counselling
160 Terence Matthews Cres. Unit F-1
Kanata, Ontario
613-246-0000
INTAKE FORM
It is very important to me that I spend some time getting to know you. Please take some
time to fill out the following referral form.
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Date of referral:
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Child/Youth Name:
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Date of Birth:
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Address:
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Contact Number:
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Parent / Guardian name:
Address:
Email:
Parent/ Guardian name:
Address:
Email:
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Cell:
Cell:
Others living with child:
1.
2.
3.
4.
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School your child/youth is currently attending:
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Grade:
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Has there been a formal assessment / diagnosis, including developmental disability? (Please briefly explain)
Think about strengths of your child and family, at school and in the community. (What would
someone who knows, admires or respects you, say about you?)
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About your child:
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About your family:
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At school:
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In the community:
Risk Review - Please help to identify if there are any risk factors for your child
Yes
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Child/Youth experienced any form of abuse including physical,
emotional, sexual, or neglect? Witnessed family violence?
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Has Child/Youth been aggressive toward others and or used weapons
to threaten others?
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Child/Youth lost interest or receive no pleasure in usual activities?
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Child/Youth experienced significant trauma in their life?
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Child/Youth thought or talked about suicide?
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What are the challenges your child is currently facing?
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What in particular has brought you to contact us today?
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What in the past has been helpful for your child and family?
No