Connecting Through Play
Caregiver Intake Form
Parent/caregiver name: _______________________ Occupation: _______________________
Marital Status: _____________ Age: ______________ Phone #:________________________
Email: __________________________ Address: ____________________________________
What is your preferred method of contact?__________________________________________
Fill out below who is living in the household:
Name
Relationship
Age
Additional Information
Describe the relationship between the caregiver(s) and child(ren) listed above:
____________________________________________________________________________
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What do you hope to get out of the Parenting Through Play Workshop?
____________________________________________________________________________
____________________________________________________________________________
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Describe the amount of quality time you spend with your child(ren):
____________________________________________________________________________
____________________________________________________________________________
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Describe what quality time looks like between you and your child(ren):
____________________________________________________________________________
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Which child are you most concerned about? Why?
____________________________________________________________________________
____________________________________________________________________________
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Circle some qualities that describe the child you are most concerned about:
Withdrawn
Funny
Anxious
Creative
Physical sickness
Critical
Angry
Reserved
Helpful
Resourceful
Carefree
Fatigue
Independent
Moody
Irritable
Clingy
Compassionate
Quiet
Silly
Hyperactive
Aggressive
Intelligent
Thoughtful
Sad
Appetite Change
Courageous
Other: _______________________________________________________________________
Where did you hear about the Parenting Through Play Workshop?
____________________________________________________________________________
Any additional comments or concerns:
____________________________________________________________________________
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