How did you hear about my Counselling services?
Name of Child
Age of Child/DOB
School Attending and grade
If you are the Guardian or adopted parent, please fill out a form for yourself and a separate one for details of the birth parents
Current Parents or Guardians names
Education Level of First Parent
Less than high school graduation
High School Graduation
Education Level of Second Parent
Less than high school
Information of first parent - full house address
Second Parent Information If Different Full House Address
If you have a court Order re Custody /Guardianship/Access, what are the details?
Other Phone Number
Name and Age of Siblings
What are the occupations of the family members?
If you have been married/connected before, when were you married/divorced? Did you have any children?
Religious Affiliations in the Family
What are the ethnic backgrounds of your family?
Have members of the family had any illnesses?
Has your family lost a baby/child before birth? When?
What other deaths/losses has your family experienced?
What hobbies do members of your family have?
What brings you to see me?
What would you like to be different for your family?
What would you like to be different for your child?
What do you think your child wants to be different for themselves?
What kind of parents do you believe to be?
What parenting techniques have you tried and what works?
How do you decide how to parent your child? What happens when you do not agree?
What are your child's strengths?
What are the parent's strengths?
How do you think your child wants to be different in the family?
Are you covered under Criminal Victims Assistance Program. If yes please give your claim number and number of sessions
Agreement My signature below confirms that I have read the above, had an opportunity to discuss it with the counsellor, and had my questions answered to my satisfaction. I also give permission for Madeleine De Little the counsellor, to contact my child’s school, and for photos and videos of my child’s work only, to be used as a teaching tool.