PRE-CALL QUESTIONNAIRE

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Thank you for taking the time to fill out this form. It will give me the information I need so we both can get the most out of our call together.

Your name:

Your e-mail address:

What is the best phone number to reach you at?

Child's name:

Child's age:

YYYY

Are you the child's primary caregiver?

yes

Clear selection

Does your child have a diagnosis?

What kind of diet is your child currently on?

Picky eater- only eats a few foods

Typical eater- standard pizza, fries, mac & cheese

Mostly healthy- I focus on healthy food but my kid enjoys typical junk food as well

Special diet- I have introduced my child to a gluten-free and dairy-free diet

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Does your child have any allergies to medication, supplements, or food?If yes, please explain.

How often does your child get sick per year, on average? Has your child been on antibiotics multiple times?

What therapies or approaches have you tried?

Medication

Dietary changes

Alternative therapies (e.g., acupuncture, chiropractic care)

Behavioral interventions

Parenting classes

OT/PT

Supplements

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How would you descibe the impact of your child's challenges for you?

Is your child's secondary caregiver/spouse supportive of diet changes and natural solutions for your child's symptoms?

Do you feel you have the support you need to implement changes to your child's diet and lifestyle?

Yes

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How much are you willing to invest in a program that reduces or solves your child's symptoms? ( this helps me understand which solution fits your needs at this time)

$600- $1000

$3000 plus

It is a real stretch for me to invest right now

I am willing to invest, I know it is so important, but I need a payment plan

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Does anyone else involved in decision-making regarding your child's health need to be included in our call?

Yes

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Is there any additional information you would like to share about your child or your family's situation that you think would be relevant to our call?

Yes

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Thank you for taking the time to complete this questionnaire. We will review your application and contact you with further information regarding the next steps.

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