Intake Form

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Mother's First & Last Name

First

Last

Father's First & Last Name (copy)

First

Last

Address

Phone Number

Child's Gender

Child's DOB

Child's weight:

Mother's Health

Father's Health

List any complications during pregnancy or after delivery

Gestational age at delivery (how many weeks pregnant)

Vaginal or Cesarean?

Was your child breastfed? If so, how long?

If formula fed, what formula was used?

Was your child fully vaccinated according to schedule?

How was your child's first year of life, did they meet developmental milestones? Did they crawl? At what age did speech develop?

How was your child’s first year of life, did they meet developmental milestones appropriately?

Did your child ever experience a regression? If so, when, and what skills were lost?

What traditional therapies has your child participated in and were they helpful?

How is your child’s sleep?

How are your child’s digestion and bowel habits? Please list frequency and texture of bowel movements:

How is your child's diet, are they currently on any restrictive diets or trialed any in the past? Are they a picky eater? Please list a sample of days diet.

Does your child have self stimulatory or repetitive behaviors? Is so, please list below:

Is your child in school? If so, what grade? Are they receiving any accommodations or do they have an IEP? How are they doing in school? Please explain.

Please list all of your child’s CURRENT supplements, including dosages:

Can your child swallow capsules? Which forms of supplements do you prefer to use: liquids, capsules, chewable tablets, gummies, etc.?

Your name

Intake Form

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