First name

Last name

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Who/what were you referred by?

Parent(s) Name(s)

Birthday

Favorite Color

Reading Level

Grade/School

Dominant Eye / Ear (If Known)

Dominant Hand / Foot (If Known)

F/u Profile (If Known)

Allergies

Medications

Nutrition

Birth Trauma

Sleep Patterns

Age Started School

Alcohol Usage

Has there been emotional trauma?

Have there been any dangerous or frightening experiences?

Has there been any separation from the primary caregiver during the first four years of life?

Visual Integration

Do you wear glasses?

Auditory Integration

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Your Signature

How would you describe your self image or self-esteem?

What three goals do you have for this process?

Is there anything else you would like me to know about why you were here?

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Your Signature