Intake Form
Thank you for taking the time to fill out the following questions. Please submit the completed version back to me as soon as you can. All your information will be kept confidential.
Name *
What is your main parenting concern? *
What have you done in the past to work on this condition? (include both alternative and traditional modalities.) *
What has proven effective? *
What is your family's current diet like? Please be specific; list breakfast, lunch, dinner, and snacks, as well as the times you eat. *
What would you like to see change inn the next 30 days from now? How about 90 days from now? How would you feel if you got this result? *
What obstacles, challenges, and struggles do you come up with regarding the life of a parent *
What do you hope to get out of our time together? *
What are 5 things you LOVE about your life? *
Do you smoke?
Clear selection
On a scale of 1-10, how ready are you to quit?
Not at all ready
Already Starting to Quit
Clear selection
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