Flourishing Brains Pre-Qualification Form

Flourishing Brains Pre-Qualification Form
Welcome – We're So Glad You're Here

Thank you for your interest in Flourishing Brains.
This short pre-qualification form helps us understand where things are currently at for your child and family, and whether our services are the right fit at this time.

Please complete the form as honestly and thoroughly as you can. If it seems like we may be able to support you, you'll receive a follow-up email with helpful next steps, including a link to book a free 10-minute discovery call with Dr Liana (founder of Flourishing Brains).

If you have any questions along the way, you're welcome to reach out at hello@flourishingbrains.com.au
Section 1: Parent & Child Details
Child's Full Name*

First NameLast Name
Parent #1 Full Name*

First NameLast Name
Parent #2 Full Name

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Child's DOB*

DayMonthYear
Date
Where are you located (suburb)?*
NDIS Status*

Yes – self-managedYes – plan-managedYes – NDIA-managedNo – not accessing NDIS
Section 2: Your Child’s Needs & Goals
What brings you here?*
Please share your child’s main challenges, any diagnoses, and your top 1–3 goals or priorities for their development and wellbeing.
How did you hear about Flourishing Brains?*
(e.g., podcast, book, friend, practitioner)
Which services are you considering?*

Initial Assessment + Home Care PlanOngoing Weekly Care1-Week Intensive ProgramNot sure yet – I’d love guidance
Section 3: Readiness for Care
Our care is most effective when key foundations are in place. Please answer honestly—this helps us guide you with care and clarity.
Are you within 60 minutes of Point Lonsdale, VIC?*

YesNo, but I’m willing to travel for weekly or intensive careNo, this may not be practical for us
Our care typically costs $300/week. Is this viable for your family?*

Yes, I can afford this level of careYes, with NDIS supportNo, this isn’t feasible right now
Are you ready to commit to the following?*

Attending regular sessionsDaily home exercises (2x/day)Purchasing of assistive tools/tech for optimal home careAdjusting screen timeSupporting sleep/nutrition/stressParticipating as a parent
Have you already explored any of the following?*

Reducing screen timeGut health/dietary changesSleep/stress managementOTSpeech therapyNaturopathyNone yet
Would you be open to starting with these foundational steps first before progressing to functional neurology therapy?*

YesNo
Section 4: Final Reflection
What excites you about this approach and why does it feel like the right next step?*
Is there anything else you’d like to share?
Should be Empty:

Flourishing Brains Pre-Qualification Form

Welcome – We're So Glad You're Here

Section 1: Parent & Child Details

Section 2: Your Child’s Needs & Goals

Section 3: Readiness for Care

Section 4: Final Reflection