Empowered Parents Assessment Form
Our programs are designed to help families connect with each other and use empathy to build a healthy, family-based approach to anxiety, autism, ADHD, OCD and Trauma management. Our programs will change the life of your child and family. 

Please help us serve your family better by providing us with the information asked within this form.


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Please tells us which program you are interested in
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Parent/Guardian Information
Please provide us with contact information for both parents/guardians of the child
Parent/Guardian 1Information
 Parent/Guardian 1Name  
Parent/Guardian 1Birthday
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Parent/Guardian 1Address
Parent/Guardian 1Home Phone Number
Parent/Guardian 1Cell Phone Number
Parent/Guardian 1Email Addresses
Parent/Guardian 2 Contact Information
Parent/Guardian 2 Name
Parent/Guardian 2 Birthday
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Parent/Guardian 2 Address
Parent/Guardian 2 Home Phone Number
Parent/Guardian 2 Cell Phone Number
Parent/Guardian 2 Email Addresses
Please Help Us Learn More about Your Child
Please provide the following information about your child(ren).  
Child's Information
Child's Name
Child's Primary Address
 Birthday
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Family Doctor's name, address and phone number
Paediatrician's name, address and phone number
Naturopathic Doctor's name, address and phone number
Does your child currently see other health practitioners or therapists such as chiropractic, massage therapy, speech language, OT homeopath, naturopath, music therapy, etc
Has your child participated in ABA
Please list any medications
Do you use any supplements? What for?
Does your child take any over the counter medications?
Does your child have any known food, environmental, animal, or drug allergies?
List any illness (physical & mental) with which your child has been diagnosed.
 Has your child had any surgeries? Explain?
Do you have a personal/family history any of the following?
How many bowel movements does your child have daily? Explain.
How does your child sleep? About how many hours a night?  
Do you see any patterns in food & mood throughout your day?
LIFESTYLE  
Does your child attend school or work? If Yes, where?
How many hours a day?
How active is your child?  What type exercise and what duration?
DIET
Currently, are you using any special diet with your child?  Have you in on any special diets in the past?
Are there any foods that bother your child? Such as heartburn, bloating, digestive distress or gas?
Are there any foods that your child craves?
How is your child’s appetite?
How often do you eat in restaurants or have take out?
How many fruit and vegetables does your child eat daily?
What foods are your child’s favourites?
What kind of treats does your child eat?
 How often does your child eat bread, rice, and pasta? What kind is it?
Does your child eat meat? What kinds and how much?
Does your child eat dairy? What kinds and how much?
Do your child eat beans/legumes? What kinds and how much?
Does your child eat fish? What kinds and how much?
Are there foods that you would love for your child to eat?
When you give your child a new food how successful are you?
Tell us about a typical food day for your child.
Breakfast
Mid Morning Snack
Lunch
Mid Day Snack
Supper
Evening Snack
Daily Fluids
How many units of each does your child drink in the course of a day? Pick number of cups.
Soft drinks (Regular & Diet)
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Milk (skim, 1 or 2%)
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Water
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Flavoured Water
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Fruit Juices
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Yogurt Drinks
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Other
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Sensory Information
Pick from 1 - 5 - 1 being very little, 5 being excessive/constant
Mouthing objects
Does your child like to chew on clothes, fingers, plastics?
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Seeking Deep Pressure
Deep hugs, lying flat on the floor, likes weighted blankets, pressing against things while sitting to standing
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Excessive touching of objects
Like fidgets? Strokes items and textures?
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Sensitive to loud noises?
Hands over ears, runs from noises, does not like loud music, fear of toys that talk ?
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Bothered by lights
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Smelling objects or items
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Bothered by smells  
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Uncomfortable in their clothes
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Other, please describe
Administrative Questions
The best times of the day for my session are: (Provide us with a few options and add your time zone)
Funding Information
Does your family have health insurance coverage?
If yes, who is your insurance provider?
Will you be using any Employee Assistance Program Funding
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Would you like to receive Empowered Parents emails and updates?
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