Lambs for Children T 613 476.1128
Name _______________________________
DOB SEX __________________
Address______________________________________________
Telephone___________________________________________
Next of Kin___________________________________________
Siblings/ages:_______________________________________
Who referred you?___________________________________
Please describe all aspects of Loss ie, death, divorce, critical illness, multiple foster-homes, attachment disorder etc.
How would you describe your family/child/life?
Physical ailments – food allergies/sleep patterns
Past Group Experiences:
Have you ever had counselling before? Group/individual.
Does the child know about the group?
How does your child express himself? Talkative or not:
Favorite activities:
And is there anything else you feel we should know about you/child?
Is the child taken medication?
epi pen – allergies:
Other issues:
Selected for Group:
Emergency phone numbers:
