Child / Young Person's Details Gender*
Preferred Pronouns (if applicable)
College / School / Nursery Attending*
Parent / Guardian Details Relationship to child / young person*
Preferred method of contact*
Who referred the child to art therapy?*
Reason for referral (please provide a brief summary of your concerns)*
Does your child have any diagnosis (e.g., ASD, ADHD, PTSD)?*
Has your child received any previous or current support (e.g., CAMHS, counselling)?*
Are there any family circumstances you feel are relevant (e.g., bereavement, separation, safeguarding)?*
Emotional and Social Functioning How does your child express their feelings and emotions?*
Are there any behaviours of concern (e.g., anxiety, aggression, withdrawal)?*
How does your child interact with peers and adults?*
Medical and Accessibility Needs Does your child have any medical conditions or allergies?*
Do they require any additional support or reasonable adjustments (e.g., mobility, communication)?*
Is there an Education, Health and Care Plan (EHCP) in place?*
Do you give permission for the therapist to contact the school (e.g. SENCO or wellbeing staff) if needed to support your child’s therapeutic process? If so, please provide contact details.*
Do you give permission for the therapist to contact the child / young person's GP if needed to support your child’s therapeutic process? If so, please provide contact details.*
Are there any eating difficulties or issues around food that we should be aware of? Please provide details if applicable.*
Are there any sensory difficulties related to noise, textures, or art materials that we should be aware of?*
I confirm that the information provided above is accurate to the best of my knowledge. I understand this information will help the therapist assess the suitability of art therapy for my child and plan therapeutic support.*
