Bantu Health Therapy

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

Relationship to Participant

Name of Referral

How did you hear about us

Client’s Contact Information

Name

Address

City

State

Zip

Home Phone

Cell Phone

Parent/Guardian’s Contact Information

Demographic Information

Name

Address

City

State

Zip

Home Phone

WorkPhone

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 No

Social

Please describe the participant’s social skills with peers.

Does the client have a group of friends?

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

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

Has the client been involved in any therapeutic social skills groups

Male Female

If so, please identify the group.

Intake Form

Help today because tomorrow you may be the one who needs helping!

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