BANTU HEALTH THERAPY - Multicultural kids network

Intake Form

Please fill out all information as accurately as possible. This information will assist multicultural
Kids network in determining the most beneficial placement options and bantu healing plan for
the participant described below.

Name of Person Completing Intake

Name of Referral

Relationship to Participant

How did you hear about us

Client’s Contact Information

Name

Address

City

Home Phone

State

Cell Phone

Zip

Parent/Guardian’s Contact Information

Demographic Information

Name

Address

City

Home Phone

State

WorkPhone

Zip

Client Details

General Information

Gender

Male

Female

Date of Birth

Age as of Today

Has the client ever been in African drumming therapy before? If so, where and how long?

Other Therapies: Does the client participate in any other therapies? Check that apply

Yes

Social

Please describe the participant’s social skills with peers.

Please describe the participant’s social skills with family members.

Does the client have a group of friends?

If not, what appears to be his/her specific difficulty?

Has the client been involved in any therapeutic social skills groups

Yes

If so, please identify the group.