child / teen intake form | Tictock Therapy

CHILD / TEEN TIC INTAKE (Parent Completed)

Welcome to TicTock Therapy

We specialise in tic and Tourette-related presentations using a structured, evidence-informed approach focused on nervous system regulation, tic mapping, and skill development.

All families begin with this intake form so we can provide a clinically informed recommendation within 48 hours.

SECTION 1 – Child Information

Full Name

Date of birth

Day

Month

Year

• Parent/carer names

Multi-line address

Country/Region

Address

City

Zip / Postal code

School year / educational setting

Contact Email

Contact Phone Number

GP name and surgery

SECTION 2 – Presenting Concerns

What prompted you to seek support at this time?

When were tics first noticed?

How have tics changed over time?

Please describe current tics as a list (motor and/or vocal).

On a scale of 0–10, how severe are tics currently?

When are tics most noticeable?

SECTION 3 – Premonitory Urge & Suppression

Does your child describe a “build-up” feeling before a tic?

Can they suppress tics temporarily?

What happens after suppression?

Does suppression cause distress or fatigue?

SECTION 4 – Emotional & Nervous System Profile

Please indicate if present:

Describe how your child responds when overwhelmed

SECTION 5 – Neurodevelopmental & Medical History

Diagnosis (if any):

Family history of:

Current Medication

Previous Therapy/ CAMHS involvement

SECTION 6 – Impact

How are tics affecting:

Family stress level (0–10)

SECTION 7 – Goals

1. What would feel different in 3 months if support was successful?

2. What is your biggest worry right now?

3. On a scale of 1–10, how urgent does this feel?

SECTION 8 – Commitment

Our approach typically begins with a structured 6-session foundation programme. Are you willing to commit to a structured programme?

Yes

Unsure

Not at this stage

Child / Teen Tic Intake Form (Parent Completed)

CHILD / TEEN TIC INTAKE (Parent Completed)