Children First Client & Collateral Contacts Form
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1Children First Client & Collateral Contacts Form
Include all contacts with child, parent, school, other professionals re: this child. Types of contact include: individual session,
group session, call to parent (specify who,) contacts with teachers, doctors, etc..
Student: ____________________________________________________
M
F Grade: ____________________
Therapist: ______________________________________ CF School: ____________________ Year: ___________
Parent(s):
Phone: __________________ Email: _________________
Referred by:
Teacher
Parent
Principal
Self
Other ____________________ Referral date: __________
Reason for Referral:
Date
# Minutes
Summary of Contact: detail kind of contact, who, purpose, length of time
Example:
10/22/09
20 min
Individual session with client – played in sandtray
10/30/09
10 min
Teacher conversation re: recent changes in classroom behavior, will call Mom
11/5/09
10 min
Phone call w/Mom, see note
1/5/09
.75
Group session: see individual note in this file;
jlc 7/12
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