Client Intake Form

Client Intake Form
Please complete our Intake Form to the best of your ability. Please note that, once submitted, the information is stored in a secure HIPAA compliant environment.
Full Name *

First Name Last Name
Parent Name (if under 18 years old)

First Name Last Name
Cell Phone Number *

Area Code Phone Number
Email *
example@example.com
Date of Birth *

Month Day Year
Date
Today's Date *

Month Day Year
Date
Referred by *

First Name Last Name
What are your goals? *

Early Development Sensory, Self-regulation Academic, reading, focus Anxiety Balance, Vertigo Pain Injuries Post-surgical function Staying active
If you checked more than one goal, please list the order of priority:
Please share some background information (for example, when did the issue start, how often, what else have you tried?)

	Yes	No
Are you currently pregnant?
Are you currently treated for a neurological, autoimmune condition or cancer?
Are you currently treated for a chronic pain condition such as fibromyalgia?
Have you had corrective eye surgery for lazy eye or crossed eye?
Have you had an active disc or spinal injury?
Have you experienced issues related to a traumatic brain injury (TBI)?

Please list injuries, such as auto accidents, falls, concussions, bike accidents, traumatic events, etc. For each event, please indicate your age and a description of what happened.
Please list fractures and/or surgeries including cosmetic and dental surgeries. For each event, please indicate your age and whether you had a cast, immobilization or any complications.