Date
*
MM
DD
YYYY
Parent's Name
*
First Name
Last Name
Parent's preferred pronouns?
Child's Name
*
First Name
Last Name
Child's preferred pronouns?
Name or nickname prefered if other
Child's age and birthdate
*
Best phone number for me to reach you at.
*
(###)
###
####
Mobile phone
(###)
###
####
Are you reachable by text
Your email address
*
What is your profession(s)?
Briefly explain your spiritual, philisophical, or religious orientation.
How did you hear about me?
What are a few of your child's interests?
Have they previously experienced Craniosacral Therapy or Visceral Manipulation?
What are the major stressors in their life?
Are they currently working with a therapist or counselor?
Are they currently under a physician's care for medical conditions? Please explain.
Why are you seeking treatment? What do you want to change or improve for your child with this treatment?
Have they been experiencing any of the following during the past year?
Other health conditions not listed above.
Are they currently taking percription medications?
List all surgeries with approximate dates
List concussions and major head injuries, if any, with approximate dates
List other significant injuries with approximate dates
Does your child currently have any of the following?
Your child was born at:
Would you consider your childs birth situation traumatic for them?
Is there anything else you think may be helpful for me to know?
I agree to give at least 24 hours notice should I need to cancel or reschedule a session, and pay for sessions cancelled or missed without such notice.
*
Terms and Conditions
Ko Darlington is not a licensed medical doctor nor licensed psychologist and does not practice any form of licensed medicine or psychology. He does not diagnose, cure, heal, treat disease or prescribe medication. He will not be held responsible for any damages or losses. It is recommended that clients continue to seek the advice of a licensed physician for medical conditions.
