Children Inquiry Form
Please fill out the form below as thoroughly as possible. If some questions do not pertain to you, simply write: "N/A" or "NO" in the proceeding text boxes.
Parent Name *
Your answer
Parent Name *
Your answer
Contact Phone *
Your answer
Contact Email *
Your answer
Mailing Address *
Your answer
Child's Name *
Your answer
Child's Date of Birth *
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Child's Diagnosis *
Your answer
Current medications / supplements your child is taking: *
Your answer
Please describe anything significant about your pregnancy and / or delivery. *
Your answer
Has your child had any serious injuries / operations? If so please explain: *
Your answer
What is your child currently able to do on his / her own? *
( check all that apply )
Required
If selected "other" please describe: *
Your answer
What therapies does your child receive at this time? (traditional or alternative) *
Your answer
How often do they receive these therapies and what are the current goals? *
Your answer
Is your child using support devices in therapy, home, or school settings? *
If so, please describe which ones and how often they are used? (baby swings, jumping devices, special chairs, walkers, standers, AFO’s, braces, splints, wheelchair, etc.) *
Your answer
How much floor time does your child have each day? *
Your answer
What sort of activities does your child like and dislike? *
Your answer
How would you describe your child’s nature? (quiet, inquisitive, restless, anxious, playful, etc.) *
Your answer
Please describe mealtimes with your child. (nursing, bottle fed, tube-fed, self-feed, other) *
Your answer
What is your child’s sleeping schedule? (still napping, what time of day, how long) *
Your answer
Please describe briefly your child’s daily routine. *
Your answer
Is there anything else you would like to add to help me better understand your child? *
Your answer
What short term goals would you, as a parent, like to see your child accomplish in the upcoming months? *
Your answer
Statement of Policy Regarding Intervention Modalities / Agreement and Release of Liability
Dear Parent,

As you know, my work with your child focuses on movement learning. During the course of providing lessons for your child, I may comment on or answer questions from you or your family members regarding other intervention modalities (such as braces, standers, prescription drugs, a variety of therapeutic modalities, etc.) that in my experience have proven helpful or obstructive to my particular method of movement learning. At times, these comments may appear to be in conflict with advice you are receiving from your child’s medical professionals. It is important to keep in mind that my suggestions come from a movement learning perspective, while their advice comes from a medical perspective. Every child is unique and only you, having all of your child’s medical and other information, can make the appropriate choices for your child and coordinate medical and other care in a way that advances your child’s best interests. I am not a medical provider and cannot and do not offer medical advice. Where my suggestions appear to be in conflict with the suggestions of your child’s medical providers, it is imperative that you consult with those medical providers and understand from them the consequences and risks of the totality of your child’s care.

It is your responsibility to inform the practitioner of any pre-existing conditions, limitations, specific sensitivities, or anything that may be relevant to your child’s lesson. You must inform your practitioner if at any time during the lesson you feel your child may be experiencing discomfort or pain. You understand that Jon Martinez/Movement Matters does not diagnose illness, disease, or any other disorder, and is not a substitute for medical examinations or care. You understand and voluntarily accept any risks relating to your child’s lesson and have been allowed the opportunity to ask questions regarding the inherent risks associated with your child’s lesson. You hereby release and hold harmless Jon Martinez/Movement Matters from any and all liability for injury or harm, including without limitation, personal, bodily or mental injury, economic loss, or damage resulting from your child’s lesson. Your practitioner may determine that it is unsafe to proceed with or continue any lesson due to health-related concerns. I understand that this agreement and release of liability applies to this and any and all future lessons or dealings that I may have with Jon Martinez/Movement Matters.

Sincerely,
Jon Martinez, Certified ABM for Children Practitioner

I have read and understand the foregoing statement of policy and have executed and delivered this acknowledgment as of the date indicated below: *
( Please type initials )
Your answer
Date of acknowledgement *
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