Intake Form Page – The Thriving Child

A fast and simple way to get to know you and your child so that we can tackle the solution to your concerns on our first call!

Parent Name(Required)

First Last

Child Name/Age(Required)

First Age

Medical Diagnosis

if applicable

List

Person or Clinic Who Referred You(Required)

Name

Type of Schooling(Required)

Areas of concern:

Social Skills

Emotional Regulation:

Short term memory recall/Difficulty following multi-step instructions

Fear/Anxiety:

Bedwetting/Constipation:

Sleep patterns/Picky eating:

Motor skills/Sensory Sensitivities:

Learning:

Behavior/Attention/Focus:

Other: