Youth Intake Form
Name
*
First Name
Last Name
Preferred Name/Nickname
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Location of Birth
Parents Name
*
Parent/Guardian Email
*
example@example.com
How did you hear about me?
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Main Concerns
What brings you in today? (check all that apply)
Allergies/sensitivities
Gut issues (bloating, constipation, diarrhea, nausea)
Food reactions
Headaches or migraines
Fatigue/low energy
Mood changes
Sleep issues
Focus/attention concerns
Skin symptoms (eczema, hives, acne)
Immune concerns (frequent illness)
Hormone-related symptoms (for older teens)
Stress, overwhelm, or emotional load
Other concerns you’d like to share
When did you first notice these concerns?
Have you found anything that helps or makes symptoms worse?
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Eating, Digestion & Daily Nutrition
What does a typical day of eating look like? Breakfast, Lunch, Dinner, Snack/drinks.
How would you describe their eating style?
Eats well
Picky with textures
Always hungry
Sugar or carb cravings
Avoids certain foods
Digestive patterns
Regular bowel movements
Constipation
Loose stools
Gas/bloating
Reflux or heartburn
Stomach pains
Stomach pains
How often do they have a bowel movement?
Any known food allergies or foods that don’t agree with them?
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Sleep & Rest
Usual bedtime/wake time
Do they fall asleep easily?
Do they stay asleep?
Restless, mouth-breathing, or snoring?
Do they feel rested in the morning?
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Stress, Emotions & Personality
Tell me a little about your child’s temperament:
Easygoing
Sensitive
High-energy
Anxious or worried
Withdrawn when stressed
Emotional/expressive
Irritable when overwhelmed
Any recent life changes or stressors?
What helps them calm down or feel supported?
Any known trauma or difficult experiences?
(Only share what you’re comfortable sharing — it helps me know how to support their nervous system.)
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School, Learning & Daily Structure
Grade level
What type of schooling do they currently do?
Traditional public school
Private school
Charter school
Homeschool
Hybrid/co-op
Online/virtual school
How do they feel about school overall?
Enjoys it
Neutral
Struggles
Overwhelmed
Anxious about school
Academics & learning style:
Learns best with hands-on activities
Learns best by watching
Learns best by listening
Needs extra time to process information
Easily distracted or loses focus
Very detail-oriented
Strong reader
Struggles with reading
Struggles with math
No concerns academically
Do they receive any additional support?
OT (Occupational Therapy)
PT (Physical Therapy)
Speech therapy
Counseling
ADHD or sensory support
None currently
School-related symptoms:
Headaches after school
Tummy aches before school
Emotional after school
Trouble focusing
Trouble sitting still
Easily overstimulated (noise, lights, crowds)
Screen time for school:
Minimal
A moderate amount
Heavy (multiple hours daily for academics)
Is there anything about their school environment that feels stressful or not a good fit?
If homeschooled, how is their daily rhythm structured?
Do they participate in co-ops, groups, or outside classes?
Any challenges with focus, motivation, or emotional regulation?
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Home & Environment
Any pets in the home?
Any known mold/water damage?
Diffusers, fragrances, or scented laundry products used?
Do they sleep near screens/WiFi devices?
Water source (tap, filtered, bottled)?
Any exposure to smoke, chemicals, or strong cleaners?
Medical & Wellness Background
Pregnancy/birth notes that might be relevant
Past illnesses or chronic issues
History of antibiotics (approx. how many times?)
Surgeries or injuries
Current medications
Current Supplements
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Allergies & Immune System
Any known specific allergies?
Do they have asthma?
Please Select
Yes
No
Skin reactions?
Please Select
Yes
No
Frequent infections?
Please Select
Yes
No
Slow recovery time?
Please Select
Yes
No
Any family history of allergy-related issues?
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Hormones (for ages 12+)
Has puberty started yet?
Please Select
Yes
No
For girls: cycle regularity, cramping, PMS, heaviness/lightness
Mood swings or emotional shifts
Please Select
Yes
No
Acne or skin changes? Please describe
Noticeable body odor changes
Please Select
Yes
No
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Family Wellness Background
Any family history of:
Autoimmunity
Allergies or asthma
Gut issues
Hormone imbalance
Anxiety/depression
Mold or Lyme exposure
Parasites
Other patterns that may be relevant
Has your child ever done any type of detox or cleanse before?
Please Select
Yes
No
Unsure
If yes, what kind? (Check all that apply)
Gentle detox drops or tinctures (Bioray, herbal blends, etc.)
Parasite cleanse
Heavy metal detox
Mold detox
Liver or lymph support
Juice cleanse or fasting
Bath detoxes (Epsom salt, baking soda, etc.)
Homeopathics
Probiotic or gut reset
Other
How did their body respond?
Handled it well
Mild symptoms (tired, emotional, bloating)
Strong symptoms (headaches, rashes, stomach upset)
Had to stop early
Unsure / don’t remember
Did you notice any improvements during or after the detox?
Were there any symptoms that seemed to get worse?
Are they currently on any detox or herbal supplements?
Please Select
Yes (please list)
No
If yes, please list
Is there anything you’re nervous about when it comes to detoxing?
What changes would you love to see in your child over the next few months?
What feels most important to you in this season of their health?
If you have any lab work, previous testing, notes from another provider, or anything else you feel might be helpful for me to see, you’re welcome to upload it here.(No pressure, it’s completely optional.)
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