Child Intake Form

Child Intake Form

Share your child’s background, health history, medications, and the concerns you’d like help with.
Child and Parent Information
Child Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Birth

Hour Minutes

AM/PM Option
Place of Birth
Physical Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Names

First NameMiddle NameLast Name
Parent/Guardian Email Address
example@example.com
Parents' Marital Status / Family Dynamic
Who does the child live with?

Other
Gender at Birth

Other
Gender Preference (if different from gender at birth)
School Type
Grade
Medical History and Current Treatments
Current medications and supplements
Current or past diagnoses

Other
Other therapies received
Vaccine history
Did you follow the current or an alternative schedule?
Please list any reactions your child had to any vaccines below. Include behavior changes, crying, fevers, repeat ear infections, etc.
Main Concerns or Issues Seeking Help
When did the Concerns Begin?
What else was going on in your child's life at that time (ie. New pharmaceutical products, loss, moving, illness) Do you have thoughts on what may have caused this?
Triggers, Patterns, and Additional Notes
Does anything make it better? anything make it worse?
Is there a time of day, or season of the year this is better or worse?
Pregnancy and Birth History
Was the pregnancy planned?
Food aversions or cravings during pregnancy
Medications and supplements taken during pregnancy
Did Mom receive any vaccines during pregnancy? if so, please list
Any shocks, injuries, or trauma during pregnancy
Number of ultrasounds during pregnancy
Major life changes or stress during birth
Weeks of gestation at birth
Birth and delivery checklist
How mother felt during delivery
Was mother supported during delivery?
Did the child spend any time in the NICU?
Significant events during or just after delivery
Infancy and Early Development
Was the child breastfed in infancy?
How long was breastfeeding continued?
Which gut or feeding symptoms were present in infancy?

Other
Describe how the child responded to illness during the first two years of life.
List any major, repeated, or unusual infections, diagnoses, or illnesses in infancy or early childhood.
Tell me a little about the child's temperament and personality as a baby
Age when the child sat up independently
Age when the child crawled (including whether on all fours)
Age when the child walked independently
Age when the child spoke first words or started speaking
What medicines or treatments were used in infancy? Include over-the-counter medicines, antibiotics, acetaminophen, steroids, and similar treatments.
Current Behavior, Physical Complaints, and Diet
Please tell me a little about your child's temperament and personality currently
Biggest stressors and how your child reacts when stressed
Strengths and what makes your child light up
Current behavioral concerns
Unusual behaviors you have noticed

Other
Feedback from daycare or school, if applicable
Physical complaints and what makes them better or worse
Diet description, strong food preferences or avoidances
Anything else you would like to share

RETAINER AGREEMENT AND CONSENT TO TREAT
I, ______________________________________________, hereby retain Amber Bees Lombard as a homeopathic consultant.

I understand that she does not seek to diagnose, treat, or prescribe for illness, injury, disease, disorder, or other pathological conditions. Instead, she seeks to stimulate my own (or my childs) defense system with the use of homeopathic remedies so that I can better deal with the wide variety of stresses I(or my child) experience. In exploring this homeopathic practice, I am interested in monitoring my confrontation with stress and in stimulating my own healing abilities to move through crisis naturally. I have had ample opportunity to discuss the relationship between the treatment of pathology and the employment of the homeopathic approach as practiced by Amber Bees Lombard. I agree to consult a physician for any concern about pathology which may arise during the term of this agreement, and to inform Amber Bees Lombard of such consultation and its results. In choosing this approach, I realize that some of my symptoms of discomfort may get worse before they get better, and I could elect to minimize or eliminate uncomfortable symptoms by obtaining treatment according to accepted standards of medical practice from a physician.
In order to maximize the benefit which I might receive from this work, I agree to:
Consultant, Amber Bees Lombard, agrees to elicit a history of indications relevant to my constitutional disposition, advise me accordingly, and provide me with an opportunity to undertake a homeopathic remedy according to the principles of the empirical science of homeopathy. This agreement shall remain in effect, unless terminated in writing by either party to the other.
Signature of Client/Guardian
Name of Client/Guardian

First NameLast Name
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: