NLP 4 Kidz Intake Form

NLP 4 Kidz Intake Form

Jennifer Bitran , C.
All information is strictly CONFIDENTIAL.
Date
Name

First NameLast Name
Email
example@example.com
Age
Date of birth
Gender
Mobile phone number
Please enter a valid phone number.Format: (000) 000-0000.
Additional phone number
Please enter a valid phone number.Format: (000) 000-0000.
You will receive a text message reminder the day before our appointment. Please confirm your appointment promptly by responding back with the number "1".
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of emergency contact
Phone number of emergency contact
Relationship to emergency contact
YOUR CHILD'S ISSUE
What is the issue that you're ready for me to help your child reslove?
How big of an issue is this in your child's life?
What areas of your child's life does this involve?
Do you consider this to be more of a problem, or a goal?
Are you looking for a quick fix, or are you ready to sincerely commit to doing what it takes to resolve this?
How committed are you to resolving this?
How would you rate your child's ability to follow instructions?
What have you previously invested in to help your child with this?
MORE ABOUT YOUR CHILD
What's most important to your child about resolving this issue?
What are your child's main strengths?
What are your child's main limitations?
List 5 or more of your child's most meaningful accomplishments:
HEALTH AND FITNESS
Name of primary care physician
Physician's phone number
Please list any current treatment being received from any health care providers:
Please list any current medications and dosages:
How often does your child exercise?
What type of exercise does your child engage in?
Hours of sleep required?
What is your child's normal bedtime?
Does your child have difficulty falling asleep?
does your child have difficulty staying asleep?
Which of the following physical complaints currently apply to your child?
Which of the following emotional complaints currently apply to your child?
Which of the following have ever applied to your child?
RECENT LIFE CHANGES
Health changes
Home / family changes
CANCELLATION POLICY
Cancelled or changed appointments WITH LESS THAN 24 HOURS NOTICE - as well as missed appointments - will result in a fee of $95. When a client does not honor their appointment time, and gives last minute notice - or no notice at all - it usually leaves insufficient time to fill that vacant time slot with another client. Thank you for your understanding and cooperation.
Should be Empty:

NLP 4 Kidz Intake Form

YOUR CHILD'S ISSUE

MORE ABOUT YOUR CHILD

HEALTH AND FITNESS

RECENT LIFE CHANGES

CANCELLATION POLICY