Language
  • English (US)
  • Español
  • Português
  • Child & Youth Intake Form

    Sol Play Child Therapy Inc - Owned by Shirla de Magalhães, LMFT, RPT-S,RSP License 82947 - 8453 La Mesa Blvd, La Mesa, CA 91942- 619-797-6595 www.solplaytherapy.com
  •  / /
    Pick a Date
  •  - -
    Pick a Date
  • Parent/Guardian Information:

  •  - -
    Pick a Date
  •  - -
    Pick a Date
  • Observation: If parents are divorced, copy of the current custody agreement must be shown to therapist, and signed or verbal consent by both parents must be given prior to start of treatment.

  • Medical/Mental:

  • Socialization/Recreational:

  • Educational/Vocational:

  • Please describe your child's overall experience, and or challenges during these school years:

  • Clear
  • Should be Empty: