NeuroThrive Program Questionnaire
Please take a few minutes to fill out this form about your child. The information you provide will help us determine the best next steps for your family. Our team will reach out to you within a few business days.
Child's Name
*
First Name
Last Name
Child's age
*
Parent/Guardian Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Does you child have a specific diagnosis (ADHD, ODD, Autism, PANS/PANDAS, Anxiety/Depression etc)?
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Yes
No
If yes, what is the diagnosis/diagnoses?
Did your child have a sudden onset of neurological or behavioral symptoms?
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Yes
No
Do their symptoms come and go?
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Yes
No
Do you know any triggers that worsen the symptoms? What happens?
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Have you noticed your child’s symptoms worsen after being sick, exposed to something, or going through a stressful event? If so, please describe what you observed.
Does your child have behavioral challenges, i.e. rage, anger, anxiety, excessive crying, isolation, social difficulties?
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Yes
No
Other
Does your child have repetitive behaviors or thoughts that are controlling their life?
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Yes
No
Other
Does your child have dark, destructive thoughts?
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Yes
No
Does your child have tics or other abnormal movements?
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Yes
No
Does your child have severe anxiety or phobias?
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Yes
No
Does your child get sick often?
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Yes
No
Does your child have a history of abnormal reactions to vaccines?
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Yes
No
Have you noticed a regression in a learned skills or a deterioration in school performance?
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Yes
No
Does your child have sensory issues, i.e. light, noise, texture of clothing or foods?
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Yes
No
Does your child have urinary or stool accidents past the potty training period?
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Yes
No
Does your child restrict eating?
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Yes
No
Does your child have gastrointestinal complaints (Reflux, hiccups, indigestion, gas, bloating, constipation and/or diarrhea)?
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Yes
No
Other
Can you share any history of infections or environmental exposures your child has had (for example, strep throat, chronic sinus issues, Lyme disease, or possible mold exposure)?
Is your child on any medications? If so, which ones and for how long?
*
Does your child have allergies? If so, what kind of allergy and what is the reaction?
*
Is your child under the care of another provider for these issues?
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Yes
No
If yes, who is the other provider?
What other treatments (if any) have you tried for your child?
What are your top 2–3 concerns or goals for your child’s health and development right now?
*
What are your hopes and dreams for your child?
Submit
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