Counselling Demographics Request Form Client's Name * First Name Last Name Pronouns * Age * Date of Birth * MM DD YYYY Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Client Phone Number * (###) ### #### Email * Health Card Number * Parent / Guardian Name * First Name Last Name Relationship to Client * Phone * (###) ### #### Email * EMERGENCY CONTACT INFORMATION Name * First Name Last Name CLIENT PICK-UP PERMISSIONS Please list anyone authorized to pick up this client: * Please list anyone NOT authorized to pick up this client: * If there is a custody agreement or restraining order, please give details and provide copies of legal documents: * SCHOOL INFORMATION Grade * School * My child has a; * If yes, please send us a copy ( fiddleheadcarefarm@gmail.com ) Behavioural support person at home or school Written behaviour and/or safety plan at home or school N/A MEDICAL INFORMATION Diagnosis: (list all) * Other Medical Concerns: * Allergies: (eg. drugs, food, insect stings/bites, animals, seasonal, other) * MEDICATIONS Is this client on any medications? * Yes No If yes, list all medications this client is on: * PLEASE COMMENT ON THE CLIENT'S STRENGTHS AND/OR NEEDS Physical Mobility: * Cognition ( eg. attention span, perseveration): * Communication (eg. oral, written or visuals): * Personal Care Skills: * Safety Awareness: * Sensory Needs: * Transitions: * Social Interactions: * Interests/ Hobbies: * Fears/ Aversions: * BEHAVIOUR AND COPING List any emotional/behavior concerns: * Current Coping Strategies/ Supports: * Please list any other information you think the FCF staff need to be aware of in order to help your child succeed at Fiddlehead Care Farm: * What services are you interested in? * Individual Counselling Family Counselling Life Skills AVAILABILITY Day * Weekdays Weekends Specific day(s) * Time * Morning Afternoon Afterschool Other availability comments (eg. can take client out of school, has other programs) * SIGNATURE The above information is true to the best of my knowledge and I agree to notify the staff at Fiddlehead Care Farm if there are any changes. Name * First Name Last Name Date * MM DD YYYY How did you hear about us? * Google Search Family/Friend Facebook/Instagram Doctor School Another Program Other Demographics form has been submitted and client has now been added to our waitlist. We will reach out via email with next steps.Thank you,Fiddlehead Care Farm
