Classic form

Child psychology intake form with two guardian signatures

A child psychologist needs three histories before the first session: the development, the school and the household, and the consent of everyone with parental responsibility. This twenty two field intake form collects all four, and ends with two signature boxes rather than one.

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Top of the child psychology intake form with two guardian signatures example — The top of the form as it renders. The image was generated for this example.

The form itself

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New client form

Little Minds Psychology, Adelaide. One form per child. Where two people share parental responsibility, both consent to psychological services, so there are two signature boxes at the end.

The child

Child's name *

First

Middle

Last

Child's date of birth *

Address the child lives at, including suburb, state and postcode *

Guardians

Both people with parental responsibility are recorded here, whether or not they live together, because both consent to psychological services for a child. If one of them does not have parental responsibility, write that in the custody question further down and leave the second set of fields blank.

First guardian, name and relationship to the child *

First guardian mobile *

First guardian email *

Second guardian, name and relationship to the child

Second guardian email

Why you are here

Who suggested this appointment? *

Nobody, this was our own decision

GP, on a mental health treatment plan

Paediatrician

School wellbeing team or counsellor

Another psychologist or therapist

A court or family report writer

What are you noticing? *

Worry, or fear of being away from a parent

Low mood or loss of interest

Big feelings that take a long time to settle

Anger, or damage to things and people

Trouble making or keeping friends

School refusal or morning meltdowns

Trouble focusing or finishing things

Sleep problems

Eating or body image worries

Toileting difficulties

Something that happened that they have not got over

Nobody knows what is going on, including us

Describe a recent hard day, start to finish *

Development and health

The answers below are health information about your child. They are read by the treating psychologist, kept in the clinical record, and shared only with your written consent or where the law requires it. Fill in the ages you remember for these six: first words, two words together, walking, toilet trained by day, starting childcare or preschool, and starting school.

Developmental history

#	Milestone	Age it happened	Anything you noticed at the time
1
2
3
4
5
6

Has your child been diagnosed with, or assessed for, any of these? *

Autism

Attention deficit hyperactivity disorder

A specific learning disorder

A language or speech disorder

Anxiety or depression

Epilepsy or another neurological condition

A hearing or vision problem

A chronic illness

Assessed, but nothing was diagnosed

None of these

Medications your child takes

School

School and year level *

Teacher, and what the school has said

What support is in place at school? *

Nothing formal

Informal adjustments by the classroom teacher

A documented learning or behaviour plan

Support from a school services officer

Attending a special education setting

The school does not know we are seeking help

Family and legal arrangements

What are the care arrangements for your child? *

Lives with both parents, no orders

Separated parents, arrangements agreed between us

Separated parents, parenting orders in place

Separated parents, a matter currently before a court

Lives with one parent, no contact with the other

Lives with a guardian who is not a parent

In the care of the state

Who lives in each household, and who else matters to your child? *

Previous assessments and reports

Click to upload

Max: 10MB

A psychologist or paediatrician report, a speech or occupational therapy assessment, a school learning plan or a recent report card. Photos of printed pages are fine. Images or PDF, up to 10 MB each.

Consent

By signing you confirm you have parental responsibility for this child and consent to psychological assessment and therapy. What a child says is treated as confidential in an age appropriate way, and your psychologist will explain at the first session what will and will not be shared with you. The limits are the usual ones: serious risk to your child or another person, or a legal requirement to disclose, including a subpoena. Where two people share parental responsibility, both sign. Reports for a court are a separate service and are not produced from therapy notes.

First guardian signature *

Second guardian signature, where parental responsibility is shared

Every field, and what it collects

The complete field list, in the order respondents meet it.

Child's nameNameRequired
Child's date of birthDateRequired
Address the child lives at, including suburb, state and postcodeShort textRequired
First guardian, name and relationship to the childShort textRequired
First guardian mobileShort textRequired
First guardian emailShort textRequired
Second guardian, name and relationship to the childShort text
Second guardian emailShort text
Who suggested this appointment?Single choiceRequired: Options: Nobody, this was our own decision · GP, on a mental health treatment plan · Paediatrician · School wellbeing team or counsellor · Another psychologist or therapist · A court or family report writer
What are you noticing?Multiple choiceRequired: Options: Worry, or fear of being away from a parent · Low mood or loss of interest · Big feelings that take a long time to settle · Anger, or damage to things and people · Trouble making or keeping friends · School refusal or morning meltdowns · Trouble focusing or finishing things · Sleep problems · Eating or body image worries · Toileting difficulties · Something that happened that they have not got over · Nobody knows what is going on, including us
Describe a recent hard day, start to finishLong textRequired
Developmental historyTable: Columns: Milestone · Age it happened · Anything you noticed at the time
Has your child been diagnosed with, or assessed for, any of these?Multiple choiceRequired: Options: Autism · Attention deficit hyperactivity disorder · A specific learning disorder · A language or speech disorder · Anxiety or depression · Epilepsy or another neurological condition · A hearing or vision problem · A chronic illness · Assessed, but nothing was diagnosed · None of these
Medications your child takesLong text
School and year levelShort textRequired
Teacher, and what the school has saidShort text
What support is in place at school?Single choiceRequired: Options: Nothing formal · Informal adjustments by the classroom teacher · A documented learning or behaviour plan · Support from a school services officer · Attending a special education setting · The school does not know we are seeking help
What are the care arrangements for your child?Single choiceRequired: Options: Lives with both parents, no orders · Separated parents, arrangements agreed between us · Separated parents, parenting orders in place · Separated parents, a matter currently before a court · Lives with one parent, no contact with the other · Lives with a guardian who is not a parent · In the care of the state
Who lives in each household, and who else matters to your child?Long textRequired
Previous assessments and reportsFile upload: A psychologist or paediatrician report, a speech or occupational therapy assessment, a school learning plan or a recent report card. Photos of printed pages are fine. Images or PDF, up to 10 MB each.
First guardian signatureSignatureRequired
Second guardian signature, where parental responsibility is sharedSignature

What each block of this form collects

The child block is three fields, and the address is asked as the address the child lives at rather than the respondent's, because in separated families those differ. The guardian block records two people, with a paragraph above it explaining why, and the second guardian email exists so a consent form can be sent to somebody who is not filling this in. The concerns block pairs a twelve item tick list with one open question, describe a recent hard day start to finish, which is the single most useful field on the form. Development, diagnoses and medications follow. School is three fields including what the teacher has actually said. The family block holds the care arrangements radio and a household question that asks who else matters to the child, and the uploads carry the reports.

The Australian pieces on this form

Two things here are shaped by Australian practice. The referral radio names a GP mental health treatment plan, which is the route most children reach a private psychologist by and which comes with a limited number of rebated sessions and a report back to the referring doctor. It also names a court or family report writer, because a child referred that way arrives with a different purpose and the practice needs to know before the first session. The consent paragraph then draws the line: reports for a court are a separate service and are not produced from therapy notes, which protects the therapy from becoming evidence. The care arrangements radio covers parenting orders and a matter currently before a court, since both change who may consent and who may be given information.

How to adapt this form

An assessment only practice doing cognitive and learning testing replaces the hard day question with the referral question in writing, what decision the assessment is meant to inform, and adds previous test dates, because cognitive tests cannot be repeated too soon. A school based service drops the two signature blocks for a single school consent and adds the year coordinator as a named contact. A practice working with adolescents moves the consent conversation to the young person, adds a field for what they know about the referral and whether they agreed to it, and keeps only one guardian signature where the young person can consent for themselves.

What makes this form work

The tick list ends in nobody knows what is going on

Twelve things a guardian might be noticing, and a last option that admits confusion. Plenty of families arrive without a label, and forcing them to pick one produces a wrong answer that the first session then has to undo.

Two guardian fields and two signatures, not one of each

The second guardian email exists so a consent copy can be sent to somebody who is not filling this in, and the second signature is optional so a sole guardian can still submit. The requirement is made visible rather than assumed.

The household question asks who else matters

Siblings with ages, step parents, grandparents, pets, and anybody the child would mention first. That last instruction is what turns a family composition field into something a psychologist can open the first session with.

Questions people ask

Why does the form need two guardian signatures?

Because consent to psychological services for a child normally comes from everyone with parental responsibility, and that does not stop at separation. Two boxes make the requirement visible rather than assumed, the second one is not required so a sole guardian can still submit, and the second guardian email lets the practice send a copy where one is needed.

Why ask a guardian to describe a recent hard day?

Because a tick list gives categories and a hard day gives sequence. What happened first, what the child did, what the adult tried and how it ended tells a psychologist about triggers, pacing and the family response in a way that worry or anger never could. It is the field most often read twice.

What does the care arrangements question change?

Who may consent, who may be told what, and how carefully notes are written. Parenting orders and a matter before a court both mean a third party may eventually see the file, and the consent paragraph says plainly that reports for a court are a separate service rather than something drawn from therapy notes.

Why is the school support question ending in the school does not know?

Because that is a real and common position, and a psychologist who assumes the school is involved will suggest things that expose the family. Naming it as an option lets the guardian say so once rather than manage the misunderstanding in session, and it shapes what the psychologist offers to do next.

What can be uploaded to the reports field?

A psychologist or paediatrician report, a speech or occupational therapy assessment, a school learning plan or a recent report card. The upload takes images or PDF at up to 10 MB a file, which covers a full assessment report plus a couple of school documents. Photos of printed pages are fine.

Is what my child says in therapy confidential from me?

Partly, and the consent paragraph says the psychologist will explain how at the first session. Children are given age appropriate confidentiality because therapy does not work without it, while a guardian is kept informed of the direction and of anything that affects safety. The limits are risk to anyone and a legal requirement to disclose.

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Sources

Written and checked by the OneCraft team. Last checked 29 September 2026.