Intake Form

Confidential Intake Form

Today's Date *

Child's Name *

First

Last

Child's DOB / Age *

Parent's Names *

Home Address *

Home Phone & Cell Phone *

Email *

Parent 1 Occupation, Work Phone *

Parent 2 Occupation, Work Phone *

Child's symptoms and parent's concerns *

Child's clinical diagnosis (if any) *

Information about your child's birth and health in the first days/weeks of life *

Brief treatment history *

What is your child's current program, including pharmaceutical drugs, naturopathic supplements, homeopathy, diet, early intervention services, bodywork, at-home practice, etc? *

What has been most helpful? *

What has been harmful, if anything? *

Other sibling's names and ages *

If adopted, from where, what age? *

What are their special needs, if any? *

Pediatrician's name and address *

Child care, daycare, school, or home school program *

How did you hear about Amajoy? *

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