Taming Worry Dragons Summer Camp Intake Form

Taming Worry Dragons Questionnaire

A message from Miss Alicia

Welcome and thank you for joining me in this Summer Camp session of Taming Worry Dragons. My name is Miss Alicia and I have pleasure of leading our program, and most of all I am really excited to meet you! Please take a moment to answer the pre- interview questions for me. These questions help me to get to know some of the worries that the kids are facing so that I can put together a program that will be the most helpful for everyone. If you should have any questions please feel free to email me at amcghie@fsca.ca. I can’t wait to meet you IN PERSON in August! Sincerely , Miss Alicia
Child's*
First Name Last Name
Child's Birthday*
Parents Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Contact Information*
Phone Number Email Address
1. What appears to be worrying your child?*
2. What behaviours is your child demonstrating that suggest anxiety?*
3. How long has your child been demonstrating these behaviours?*
4. What is your CHILD'S level of coping regarding their anxiety symptoms?*
- 1- Has great amounts of difficulty
- 2
- 3- Has some amount of difficulty
- 4
- 5- Feeling confident
5. What is YOUR level of coping regarding your child's anxiety symptoms?*
- 1- Has great amounts of difficulty
- 2
- 3- Has some amount of difficulty
- 4
- 5- Feeling confident
6. Are there any other behaviour concerns?*
7. Does your child have a mental health diagnosis currently?*
8. Is there a family history of anxiety that you are aware of?*
9. Tell me about your child's experience with anxiety in the classroom.*
10. Has your family had any involvement with Child Welfare/Child Protection?*
11. Is there anything else we should know about your child to best support them in the group?*
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