Child's Name
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First Name
Last Name
Today's Date
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MM
DD
YYYY
Child's Age
*
Date of Birth
*
MM
DD
YYYY
Parents' Names
*
Parents' Preferred Pronouns
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Numbers (home, work, mobile)
*
Parents' Occupations
*
Siblings' Names and Ages
Referred By
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What is the main reason you are seeking somatic therapy for your child at this time?
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What medical conditions or health issues does your child have? Any disabilities or developmental delays?
What do you see as the most stressful events or conditions your child has experienced?
What has been most helpful to your child, and your family, in coming through these experiences?
Please tell me about your and your child's prenatal and birth experiences, including any complications during pregnancy.
What injuries, surgeries and major illnesses has your child had?
Please list any allergies or sensitivities your child has.
Please describe your child's inborn temperament (activity level, intensity, attention span/frustration tolerance, mood, adaptability).
What are your child's favorite activities? Talents?
What do you most admire and respect about your child? (Each parent should answer separately.)
What traits or behaviors in your child have been most difficult for you? (Each parent should answer separately.)
Is your child currently taking any prescription medications or natural remedies or supplements (homeopathic, herbal, nutritional)? Please list.
Please list the names of your child's physician and any other health practitioner or therapists your child sees.
Has your child been in therapy previously? If so, what type, for how long, and how did the therapy conclude?
Is there anything else you would like me to know?