1. Child Information Full Name: Date of Birth: Gender:MaleFemale ID Number (Passport/ID): Nationality: Registered Municipality: 2. Family and Contact Information Parent/Guardian Name: Parent Phone (International): Parent Email: Emergency Contact Name: Emergency Contact Phone: Emergency Contact Email: Address: 3. Health and Development Information Allergies or Sensitivities: Current Health Conditions or Diseases: Medications and Treatment Processes: Developmental or Behavioral Issues: Previous Therapy / Rehabilitation Type and Duration: Assessment and Results: Current School and Class: Learning Difficulties or Attention Issues: Social and Emotional Development Information: 4. Counseling and Rehabilitation Request Reason for Application and Main Issues: Goals and Expectations: Requested Support and Therapy Types:Individual EducationBehavior TherapyPlay TherapyChild and Adolescent CounselingFamily TherapySpecial Education and Development ProgramsPsychological CounselingOther Other (please specify): Additional Notes or Special Requests: 5. Consent and Privacy I confirm that the information provided is accurate and may be used in accordance with privacy policies. This information can be shared with the child counselor and relevant education/therapy teams. Parent or Legal Guardian: Date: