Initial Questionnaire & Therapy Contract

Part 1 — Initial Questionnaire

Parent 1 / Guardian

Full name *

Passport / ID number *

Relationship to child *

Current full address *

Contact information (preferably WhatsApp) *

Email address *

Parent 2 / Guardian (if applicable)

Full name

Passport / ID number

Relationship to child

Contact information (preferably WhatsApp)

Email address

Emergency Contact

Emergency contact (relationship, name, phone) *

Child / Adolescent Information

Child's full name *

Date of birth *

Gender *

Country of origin *

School / educational setting *

Current living situation *

Reason for Seeking Therapy

Please briefly describe the main concern(s) that bring you here *

When did these difficulties begin? Is there anything that may have triggered them?

Child's Mental Health & Development

Has your child ever received any diagnosis? *

Yes No

If yes, please specify:

Has your child seen a therapist or mental health professional before? *

Yes No

If yes, please provide details:

Is your child currently receiving any support at school?

Yes No

If yes, please describe:

Is your child currently taking any medication? *

Yes No

If yes, please list:

Family & Support

Is there any relevant family context you would like to share?

Goals for Therapy

What do you hope your child will gain from therapy?

Is there anything important for me to know before our initial meeting?

Part 2 — Therapy Contract

1. Introduction

Welcome to my practice. This contract sets out the terms of our work together, as an agreement between myself and you as parents or guardians, regarding the therapy I will be providing to your child.

2. Parental Consent

By signing this contract, the parent or legal guardian gives their informed consent for me to provide psychotherapy sessions to their child. You confirm that you have parental or legal authority to grant this consent, and agree to support the therapeutic process through regular attendance and engagement in parent meetings when invited.

3. Confidentiality & Third-Party Communication

In some cases, communication with third parties - such as a psychiatrist, doctor, teacher, or school - may be useful.

By marking this section, you give your general consent for me to:

Receive and review reports, diagnostic assessments, or educational records you choose to share.
Communicate with a psychiatrist, doctor, teachers, school staff, or other professionals involved in your child's care, where appropriate. Any such communication will always be discussed and agreed with you in advance.

This consent can be withdrawn at any time by informing me in writing.

4. Limits of Confidentiality

I am fully committed to maintaining the confidentiality of your child's therapy. Everything shared in sessions is kept strictly private. The only exceptions where confidentiality may be broken without prior consent are:

There is a disclosure of intent to harm the child or others.
There is suspicion or evidence of abuse or neglect.
There is any other identified risk to the child's safety or wellbeing.

5. Psychotherapist's Responsibilities and Limitations

I do not provide emergency services. In case of emergency, please contact the nearest hospital.
I do not prescribe medication. Referrals can be made if needed.
If your child's needs are outside my expertise, a referral to a specialist will be offered.
I cannot provide statements for court procedures unless legally required.

6. Payment and Cancellation Policy

Pre-payment is required to confirm each session.
Please give at least 24 hours' notice to cancel or reschedule. Cancellations within 24 hours, or no-shows, will be charged the full session fee.
Each session lasts 50 minutes.

7. Discontinuing Therapy

You are free to end therapy at any time. However, it is advisable to discuss this in advance and consider a final session or more for closure, in the best interest of your child.

Parent / Guardian full name (as signature) *

Child's full name *

Date *

I confirm that I have parental or legal authority to consent to therapy for my child, and I agree to all the terms outlined in this contract. *

I give my consent for the therapist to receive relevant reports or assessments, and to communicate with school staff or other professionals when appropriate and following prior discussion with me. *

I confirm that I have provided honest and accurate information in the questionnaire above. *

Part 1 — Initial Questionnaire

Parent 1 / Guardian

Parent 2 / Guardian (if applicable)

Emergency Contact

Child / Adolescent Information

Reason for Seeking Therapy

Child's Mental Health & Development

Family & Support

Goals for Therapy

Part 2 — Therapy Contract

1. Introduction

2. Parental Consent

3. Confidentiality & Third-Party Communication

4. Limits of Confidentiality

5. Psychotherapist's Responsibilities and Limitations

6. Payment and Cancellation Policy

7. Discontinuing Therapy

Thank you!