Child Intake Form

Child Intake Form 2019-01-02T00:20:36+00:00
Child Intake Form
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For the best results and for your child’s welfare, it is very important that you take a few minutes to read and understand what it means for your young one to be in psychotherapy.  This form provides a brief description of what you might expect if you haven’t had them in therapy before.  If you understand the information on this form and choose to begin treatment sign and date this form and return it to your child’s therapist upon intake. If you have any questions or concerns about the information on this form, you are urged to discuss them with your child’s therapist.

Psychotherapy is a special kind of health care service.  The goals of psychotherapy are to help children and parents find solutions to problems that may be limiting their lifestyle satisfaction, and to help them cope better with the feelings and challenges that your child may be encountering in their daily life.

The most common method of psychotherapy involves the child talking about their thoughts and feelings, problems or concerns, and their experiences.  Other common methods involve the use of their imagination, active play and role-playing, keeping personal journals of their experiences, and trying new and/or different ways of thinking, acting, or feeling.  These methods may be used within treatment sessions or you may be asked to do them together at home.

To better understand your child’s, thoughts and feelings, many psychologists use a variety of tests or measures to estimate their current abilities and ways of experiencing things.  These measures are important in choosing the treatment method that is best suited for your child, and they are also helpful in estimating their progress.

The length of treatment often depends on your individual goals as a parent and the rate of their progress toward the agreed upon goals.  Many psychologists use periodic reviews as a means of evaluating your needs, progress, and satisfaction.

Most children benefit from psychotherapy.  The most common benefits include improvements in self-awareness, self-esteem, self-confidence, organization, hope, feeling understood, relationships with other people, emotional expressiveness, and taking an active and responsible role in life.  There are also some risks to being in psychotherapy.  The most common risks are temporary periods of emotional distress related to changes in their life situation and their changing relationship with yourself and others (including your therapist).  This is typically viewed as therapeutic growth and can be met with resistance.  Psychological harm caused by psychotherapy is rare, but you should be aware that it could happen.  The most common causes of such harm are poor communication or unethical conduct.  If you feel that your child is not making reasonable progress or that they are being harmed by their involvement in psychotherapy, you should discuss this with your therapist immediately.  If you feel that your therapist has attempted to violate you or your child in any way – financially, physically, sexually, or otherwise – you should inform the state licensing board.

You always have the right to choose whether or not to continue in psychotherapy.  If you feel that you and your child might work better with a different therapist, your current therapist should be able to offer information on alternative referrals.  Local mental health agencies are listed in the telephone book and may also offer helpful information.  The more common alternatives to psychotherapy are:  self-help or support groups, therapeutic reading, and different forms of religious counseling.

Communication is essential to successful psychotherapy.  You are urged to ask questions, express concerns, and share information about your personal and family life with your child’s therapist.  This information will be kept confidential (private) by your therapist unless you grant permission to release it to a third party.  The ONLY EXCEPTIONS to this protection of your privacy are dictated by state laws.  For example, your therapist is legally obligated to report incidents of child abuse or threats of violence that may place you or another identified person in danger of personal harm.  You are urged to discuss this issue and the limits of confidentiality with your child’s therapist.

Your signature below indicates that you have read and understood the above description of psychotherapy and consent to have your child in psychotherapy with the understanding that you retain the right to review and revise the decision at a later time.

Please note that all name fields will also be treated as this form being digitally signed. Dr. Malcolm Anderson Ph.D. may also require this form be physically signed at the practice.

Booking Fee Notice

Please note that at the end of this form you will be required to make a payment with your credit card and secure your first session with Dr. Malcolm Anderson. Without this payment, the form will not be submitted and the booking will not be made. If you are unable to make payment at this stage, please do not continue with the intake form and contact our office at (770) 582-0532 or