Play Therapy Referral

This is an online referral form for the Helping Children Succeed study that involves play therapy services for young children. The purpose of this study is to explore the influence of two forms of play therapy on social-emotional competencies of children. Potential children for this study are children ages 3 to 5 who struggle with disruptive behavior and social-emotional skills. Children will participate in 10 sessions of play therapy at the TXST Community Counseling and Wellness Center in San Marcos, TX. Play therapy services are free. Caregivers must be willing to commit to bringing their child to weekly play therapy sessions and complete the pre/post measures. Please complete the form below to refer a child for this study.

This form is being completed by: *

(i.e., your name)

Relationship to child: *

(e.g., mom, dad, stepparent, guardian)

This form is being completed for: *

(i.e., child's name)

Child's age: *

Child's sex: *

(e.g., female, male, non-binary)

Contact phone #: *

May we leave a message at this number? *

Email: *

May we contact you via email? *

Home address: *

How did you hear about our play therapy services?

Does your child attend the TXST Child Development Center? *

What is the presenting problem or concerns you have regarding your child? *

How are you hoping that play therapy can help your child? *

Does your child sometimes struggle with disruptive behavior (e.g., anger outbursts, screaming, fighting with others, etc.)? *

Does your child sometimes struggle with social skills (e.g., making friends, communicating with others, sharing, playing well with peers, etc.)? *

On a scale of 0 to 10, with 0 being no concern at all and 10 being extremely concerned, how concerned are you about your child and their presenting issues? *

What have you tried with your child to address the presenting problem? *

What has your child tried to address the presenting problem? *

Are there times when your child does not struggle with the presenting problem? If so, please describe these times. *

If a miracle happened tonight and the presenting problem was magically resolved, what would your child be doing different tomorrow that would let you know that the miracle happened? *

What goal or goals would you like your child to work on in play therapy? (e.g., increasing coping skills, expressing feelings, decreasing disruptive behaviors, increasing self-esteem, etc.) *

What are your child’s strengths? *

What are your child’s hobbies or activities they like to do for fun? *

Does your child have friends? If so, describe your child’s friends. *

Counselors in Texas are required to obtain, review, and follow custody orders to ensure they are following guidelines related to consent for treatment, access to records, and custody. Do you currently have a custody agreement or court order in place for your child? If so, you will need to provide a copy of the orders to the counselor in the first session. *

Appt. day/times available: *

Choose all options that work for you/your child.

Tuesdays at 2:00p

Tuesdays at 3:00p

Tuesdays at 4:00p

Tuesdays at 5:00p

Tuesdays at 6:00p

Tuesdays at 7:00p

Other

If the times listed above don't work and you selected "Other", would you like to receive referrals for play therapy services elsewhere?

Are you willing to complete pre/post measures for the Helping Children Succeed study? *

We will review information about the study during the Caregiver Consultation.

What questions do you have about play therapy that we can answer when we reach out to you?

Is there any other information you'd like to share about your child that you think we should know?

If you happen to see this, do not fill this field.