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Child's Name *

First Name

Last Name

Parent's Name *

First Name

Last Name

Contact Number *

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Presenting Issues or Challenges *

Experienced a stressful or traumatic event

Emotional regulation and expression

Finds it hard to express how they're feeling

Behaviours of concern

Feels overwhelmed and anxious on a regular basis

Experiences low mood or often feels sad

Low self esteem, self worth and confidence

Experienced loss or a change

Experiences challenges in social settings

Other