• Type of therapy you feel might appropriate for the child or young person *
• Type of refer * - Please Select - Private/ Parent Education Health Other
• Type of funding * - Please Select - Self funded Pupil Premium Other

General:

• Is there a care order for the child? * - Please Select - Yes No
• Does the child have contact with parents? * - Please Select - Yes No
  What are the contact arrangements?*
• Is there/ has there been a social worker involved with the case? * - Please Select - Yes No
• Are you happy for us to directly contact the social worker with regards to our involvement? * - Please Select - Yes No

Referral Information:

• What is the reason for the referral?*
• What behaviours give rise for concern?*
• In your professional opinion, what may be the reason/s behind the presenting problems the child is displaying?*
• Have you tried other interventions previously with this child, what were they?*
• How would you like Play Therapy to help the child? Please state a few specific changes, i.e.Raise confidence, improve self esteem*
• Please describe your relationship with the child?*