Youth Intake Form

Child's Name *

First Name

Last Name

Date of birth

MM

DD

YYYY

Name of Parent (Guardian) *

First Name

Last Name

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

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Yes

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

First Name

Last Name

Phone

(###)

###

####

Are Parents divorced or separated?

Yes

No

How did you hear about New Earth Wellness?

Family/Friend

Social Media

Web

Advertising

Other

Type of Birth

vaginal

caesarian

Term:

premature

to term

late

induced

Checkbox

Jaundice

Heart Problems

Colic

Respiratory Problems

Was baby breast fed?

Yes

No

Any reactions?

Yes

No

Does the child have any diet restrictions?

Yes

No

Type of School:

Public

Private

Home

Other

Does child enjoy school?

Yes

No

Does child exercise regularly?

Yes

No

Does child wake feeling rested?

Yes

No

Do they have:

Nightmares

Night Terrors

Do they read books?

Yes

No

Do they make friends easily?

Yes

No

Has anyone assisted you previously for this concern?

Yes

No

Mental / Emotional

Anxiety/Fears

Depression

Mood Swings

Poor Concentration

Memory Problems

Skin

Rashes

Easily Bruised

Hives

Acne

Eczema

Itching

Nose / Sinuses

Frequent Colds

Seasonal Allergies

Chronic Runny Nose

Sinus Problems

Head & Ears

Headaches

Fever

Earaches

Loss of Hearing

Dizziness / ringing

Hair Loss

Mouth / Throat

Frequent Sore Throat

Cavities

Sores in Mouth

Immune

Frequent Infections

Swollen glands

Slow wound healing

Respiratory

Shortness of breath

Asthma

Frequent cough

Bronchitis

Wheezing

Cardiovascular

Palpitation

Chest Pain

Gastrointestinal

Stomach Aches

Diarrhea

Constipation

Bloating /gas

Change in appetite

Change in thirst

Speech / Language

Down Syndrome

Stuttering

ADHD/Executive Function

Emotional Regulation

Trauma/Brain Injury

Slurred Speech

Are there any other medical conditions we should be aware of?

Toxic Exposure

Seizure

Diabetes

Injuries/Accidents

Surgeries (metal plates/screws/rods)

The recommended daily water intake beginning the day before the 1st session and for 5 – 7 days after is FIVE 8 oz glasses. Do you expect any difficulty with this?

Yes

No

Pain Level

1

2

3

4

5

Stress Level

1

2

3

4

5

Energy Level

1

2

3

4

5

What best describes the child’s current state of physical health?

Excellent

Good

Average

Improving

Declining

Serious

Debilitated

Describe your home environment most of the time?

Peaceful

Stressful

Does your child have trouble concentrating or “brain fog”?

Yes

No

Would you consider your child’s eating habits/nutrition?

Excellent

Average

Needs Improvement

Is your child sensitive to light or loud noise?

No

Yes

Regaining and maintaining your child’s well being requires a strong personal commitment. How ready will they be to make lifestyle, diet or attitude changes that may be necessary to good health?

Ready

Somewhat

Not looking to make changes

I have read and completed the form to the best of my knowledge and understand the questions being asked on this form are being asked to better assess my current circumstances relating to my well being. *

Yes

I further understand that I am voluntarily agreeing to having a relaxation therapy session. The services provided by New Earth Wellness are not intended to diagnose, treat, cure, or prevent any disease. *

Yes

If you cancel your appointment less than 24 hours before it is scheduled to take place, you will be subject to a cancellation fee for the full amount of the session. *

I understand the cancellation policy