Child and Youth Intake Form

Parents, please fill out the form below skipping any optional questions you would rather not answer.  Questions followed by an asterisk are required. Click the submit button at the end. Thanks!

Date *
Date
Parent's Name *
Parent's Name
Child's Name *
Child's Name
Best phone number for me to reach you at. *
Best phone number for me to reach you at.
Mobile phone
Mobile phone
Are you reachable by text
http://
Please list gender and age
Have they previously experienced Craniosacral Therapy or Visceral Manipulation?
Are they currently working with a therapist or counselor?
Have they been experiencing any of the following during the past year?
Does your child currently have any of the following?
Your child was born at:
Would you consider your childs birth situation traumatic for them?
If yes, please explain
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.