Intake Form

Please note that this form should be completed by the person(s) who will be participating in therapy services. Exceptions are made if the intended client (1) is a minor (under 18) and you have legal guardianship or (2) is an adult and you have legal adult guardianship.

New Intake Form

Name of person completing form:*
First Last
Name(s) of identified client(s) if different from item 1:
First Last
Age(s) of identified client(s):*
Relationship to identified client(s) –

(i.e.: Self, adopted child, foster parent, significant other, spouse, etc.):
Phone
Email
Best time to contact:

: Hours

Minutes

AM/PM
Type of service:
Reason(s) for mental health/counseling/psychotherapy/play therapy services:
Previous therapy experience(s):
Current psychological diagnosis (if applicable):
Current medication(s) and dosage(s):
Are services court ordered?:
- Yes
- No
- I don't know
Any current DCFS involvement?
- Yes
- No
- I don't know
Availability for session:
Preference of telehealth or in-person mental health/counseling/ psychotherapy/play therapy services (Please note that In-person services are currently only available at our Chicago IL clinic location.
- Telehealth
- In-Person
- I don’t know
- No Preference
Payment Method:
- BCBS PPO
- Private pay (cash/credit)
- Aetna
- I’m not sure
How did you hear about Theraplay services?*
Friend, Colleague, Doctor, Therapist, Teacher, etc.
Any other information:
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The Theraplay Institute is dedicated to building strong families and emotionally healthy children and adults through Theraplay training, treatment, advocacy, and research.

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1224 W. Belmont Ave., Fl. 1
Chicago, IL 60657
P: 847.256.7334
F: 847.256.7370

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