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Intake Form

Child intake form

This form helps Positive Kids understand your child, family context, current concerns, school and health information, prior support, and safety considerations before intake follows up.

Complete as much as you can. Intake can clarify missing details later.
If this is an emergency or there is immediate risk of harm, call emergency services or go to the nearest emergency department.
Submissions go to intake@positivekids.ca.

Complete intake form

Website

Child name Date of birth Age Gender Address Parent / guardian name Parent / guardian email Primary phone Work phone Cell phone

Reasons for seeking services

CopingParental divorce/separationSchool problemsEating concernsSleeping problemsPTSDAnger managementFear/phobiasADHDAnxietyODDDigital bullyingOther mental health concerns

Primary reason and when these concerns began Family information and significant relationships Developmental, traumatic, or special circumstances

Social relationships

AvoidantOutgoingFight/argue oftenShy/withdrawnFollowerSubmissiveAffectionateFriendlyAggressiveLeader

Education / school information Medical / physical health concerns Current medications Allergies Counselling or prior treatment history Safety concerns, self-harm, suicidal thoughts, or hospitalization history

Behaviours you notice or your child is reporting

AggressionCyber addictionElevated moodAnxietySleeping problemsHopelessnessPhobias/fearsLonelinessSelf-esteem issuesEating disorderDistractibilityBody image issuesPanic attacksSelf injuryAngerImpulsivityWithdrawingMood shiftsSuicidal thoughtsIrritabilityFatigueAvoiding peopleWorryingDepression

Additional information that would assist the therapeutic process Typed parent / guardian signature Date

Ready to choose the next step?

Contact Positive Kids

Helping children, teens, parents, and schools find the right support through therapy, groups, learning services, and family system care.

Psychotherapy

Individual counselling
Dyadic counselling
Interpersonal skills
Intrapersonal skills

Groups

Social skills groups
Teen groups
Group counselling
Summer camps
Specialized groups

Education

ADHD Tutoring
Educational Counselling
Executive Functioning Coaching
Assessments
Educator Workshops

Family

Parent Online Course
Family counselling
Perinatal counselling
Parent workshops
Contact us

Positive Kids Psychotherapy, groups, educational services, and family system supports.

Ask Intake

Send your question and the email address where our intake team can respond.

Website Your question Email for response

Request a Time

Choose your preferred day and time window. Intake will confirm whether that time is available and offer the closest option if it is not.

Website

Parent/caregiver name Email for response Phone number Child age Service of interest First choice date First choice time window Second choice date Second choice time window Anything intake should know?

Where should I begin?

Answer a few questions and this guide will suggest a starting point on the Positive Kids site. This is not a diagnosis; intake can confirm the best fit.

What are you mainly looking for help with?

Emotions, anxiety, behaviour, confidence, or self-regulation Friendship, social skills, peer practice, or camps School, ADHD, focus, tutoring, learning, or executive functioning Parenting, family relationships, perinatal support, or caregiver guidance Assessment, learning profile, diagnosis questions, or next steps I am not sure yet

Who needs support?

Child Teen Parent or caregiver School or educator

What format sounds most helpful right now?

One-to-one support Group or camp Parent or family support Virtual support Not sure

Camp Registration

Send us your camp registration request. Intake will confirm availability, fit, and next steps by email.

Website Parent/guardian name Email for response Phone number Child name Child age Camp or program interest Preferred weeks, days, or time window Anything intake should know?

Groups & Camps Registration

Select the group or camp you are interested in. Social skills groups are 4 weeks, 1.5 hours per week, and $460. Intake will confirm fit, availability, schedule, and next steps.

Website Parent/guardian name Email for response Phone number Child name Child age Group or camp interest

Payment links Purchase Children Social Skills Group for $460 Purchase Teen Social Skills Group for $460 Purchase Summer Camp for $300

Preferred days, times, or location Goals or concerns

Parental Consent Form

Client's Name *

First

Last

Child Classroom / Teacher

Parent Name *

First

Last

Parent Email *

Parent Phone *

Emergency Contact Number *

Special Instructions

Date / Time *

Date

Time

Parental Consent for Child *

Yes, I provide consent.
No, I do not provide consent.

Terms and Conditions

A deposit is required to ensure your accepted participation in the Social Skills Group with Positive Kids.
Withdrawal of your participation must be submitted in writing to Positive Kids at intake@positivekids.ca 5 days before the start of the group in order to receive a refund of your deposit.
A cancellation fee of $250 will be applied if Participant withdraws from the program after the start of the group.

Name *

Email *

Phone

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