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.
Additional phone number
Please enter a valid phone number.
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?

MajorSeriousModerateMinor
What areas of your child's life does this involve?

Self EsteemHealthrelationships / friendshipsFamilySchool
Do you consider this to be more of a problem, or a goal?

ProblemGoal
Are you looking for a quick fix, or are you ready to sincerely commit to doing what it takes to resolve this?

Just looking for a quick fixReady to sincerely commit to doing what it takes
How committed are you to resolving this?

100%75%50%25%
How would you rate your child's ability to follow instructions?

Above averageAverageBelow Average
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?

NoYes
does your child have difficulty staying asleep?

NoYes
Which of the following physical complaints currently apply to your child?

Aches and painBlurred visionCold hands and feetDizzinessDrowsinessExcessive sweatingFainting or blackoutsFatigue or exhaustionHeadachesItchingJoint painLight or noise sensitivityMuscle twitching or crampsNumbnessOver-talkativeweakness
Which of the following emotional complaints currently apply to your child?

Antisocial behaviorCircular thinkingConstant worryingDifficulty concentratingEmotional fragilityFeeling "on edge"Feeling of a loss of controlForgetfulnessHighly emotionalIndecisivenessIrritabilityMagnifying insignificant eventsMoodinessNegative thoughts and attitudesNervousnessNightmaresPhobias or fearsRestlessnessTemper tantrums
Which of the following have ever applied to your child?

Panic or anxiety attacksEasily startledCry easily for no reasonFrequeny cryingSleeping too muchPeriods of daily sadness lasting more than two weeksCan't stop remembering upsetting past eventsWorry something is wrong with their bodyMake themselves throw up to lose weightOften feel like an outsiderFrequent arguments with people they live withDifficulty controlling temperBreak things sometimesThoughts of hurting someoneThoughts of hurting themselves
RECENT LIFE CHANGES
Health changes

An illness or injury which was very seriousAn illness or injury which was moderate severeAn illness or injury which was less serious
Home / family changes

Change in residenceMajor change in living conditionsChange in family get togethersBirth of a siblingMajor change in health or behavior of family memberParents divorceA parent remarriesRelative moves in with youDeath of a parent or siblingDeath of a close friend
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.

I understand and agree to the cancellation policy described above
Should be Empty:

NLP 4 Kidz Intake Form

YOUR CHILD'S ISSUE

MORE ABOUT YOUR CHILD

HEALTH AND FITNESS

RECENT LIFE CHANGES

CANCELLATION POLICY