Intake Form

An intake form is required before your first appointment

Please answer all questions that are relevant to your child’s issues and or condition as honestly as you can in order for Carla to understand your child’s diagnosis fully. This is very important to customize an effective program for your child.

Intake Form

Child's Name

Preferred Name or Nickname

Child's Date of Birth

Age

Gender

Mother's Information

Mother's Name

Last Name

Mother's Date of Birth

Mother's Address

Street Address

City

State

Zip Code

Country

Phone Number

Parental Status

Work Status

Primary Language Spoken

Father's Information

Father's Name

Last Name

Father's Birth Date

Address (if different from Mother)

Street Address

City

State

Zip Code

Country

Phone Number

Parental Status

Work Status

Primary Language Spoken

Names and Ages of Others Living in the Household

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

General Information

Reason for Visit

Source of Referral

Word of Mouth

Internet

Support Group

Physician

ABM Directory

Feldenkrais Directory

Other

Child's Birth History

Some description about this section

Labor

Normal

Complications

Pregnancy

Normal

Complications

If complications in Pregnancy or Labor, please explain

Anesthesia

Type of Birth

Delivery

Gestational Age/Weeks

Birth Weight lbs/oz.

Agpar Score at 1 Minute

Agpar Score at 5 minutes

Agpar Score at 10 minutes

NICU

Time Spent in NICU

Other Complications

Medical History

Illnesses, Injuries, Surgeries, & Hospitalizations since birth: (Check all that apply)

Meningitis

Encephalitis

Circumcision

Tracheostomy

Head Injury

Hernia Repair

G-Tube Insertion

Frequent Ear Infections

Bone Fracture

PDA Repair

VP Shunt

Failure to Thrive

Digestion

Frequency of Bowel Movements

Medications

Supplements

Allergies

Immunizations

If other, please explain

Child Care Information

Pediatrician or Family Physician Name

Phone Number

Evaluation Results & Date

Neurologist's Name

Phone Number

Neurological Evaluation Results & Date

Orthopedist's Name

Phone Number

Orthopedist's Evaluation Results & Date

Ophthalmologist's Name

Phone Number

Ophthalmologist's Evaluation Results & Date

Optometrist's Name

Phone Number

Optometrist's Evaluation Results & Date

Hearing Test Date & Results

Previous Therapy Interventions

County-based Early Interventions

School-based

Other Physicians & Surgeons involved in child's care with address & phone

Name / Phone Number

Complementary or Alternative Healthcare Professionals Consulted

(Check all that apply and provide name, address, and telephone of each)

Osteopath

Craniosacral Therapy

Nutritionist

Chiropractor

Homeopathy

Massage

Feldenkrais

Other

Names & Phone Numbers

Developmental History

Please note approximate age in months for each action

Rolled stomach to back

Stayed sitting when placed

Creeping hands & knees

Cruising around furniture

Jumping in place

Jumping over obstacles

Rolled back to stomach

Got self into sitting position

Rocking on hands & knees

Steps without support

Jumping over a line

Hopping 3 or more times on right foot

Rolled for locomotion

Crawling on belly

Held weight standing

Walking independently more than 10 steps

Jumping off step (note height)

Hopping 3 or more times on left foot

Walking on Toes

Falls

Baby Devices Used

Age in months & estimated hours per day

Sling

High Chair

Bumpo or other Sitter

Pac-n-Play

Swing

Johnny Jump-up

Exersaucer

Other

Manipulation

Age in months

Hands to mouth

Holding objects

Banging 2 objects together

Participating in dressing

Scribbling

Manipulating toys like pop beads or shape sorters

Dressing oneself

Feeding oneself using fingers

Holding object in both hands simultaneously

Holding Bottle

Other

Toileting

Age in months

Urinating or defecating in the toilet when placed there

Initiates use of toilet

Reliably uses toilet

Stopped using diapers

Communication

Age in months

Looks at caregiver

Smiles

Cooing and/or babbling

Gestures Bye-bye

Uses 5 words

Speaks in sentences

Feeding

Age in months

Bottle-feeding

Breast-feeding

Puree

Coarsely-ground food

Cut up table food

Activities

Favorite Toys

Favorite activities and/or positions

Response to music or singing

Photo/Video Release (Optional)

By checking this box, I grant Movement to Wholeness permission to use pictures and or videos of my child for the following purposes:

Website: Show the positive impact of Movement to Wholeness therapy on our website.
Presentations: Share success stories in presentations to educate other professionals and families.

I hereby authorize Movement to Wholeness to publish photographs and/or video clips taken of the undersigned minor children, and/or names, for use in Carla's presentations and/or printed publications and website.

I release Movement to Wholeness from any expectation of confidentiality for the undersigned minor children and attest that I am the parent or legal guardian of the children listed below and that I have the authority to authorize Movement to Wholeness to use their photographs and/or video clips and names. I acknowledge that participation in publications and website produced by Movement to Wholeness confers no rights of ownership whatsoever. I release Movement to Wholeness, its contractors, and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned minor children.

I Agree

I Agree - but blur their face in Photos/Videos

I Do Not Agree

Connecting with Other Families (Optional)

Movement to Wholeness understands the power of community and support. We may, with your permission, connect you with other families who have children with similar conditions.

Would you like to be connected with other families?

Upload Photos / Video

Importance of Submitting Pictures and Videos Before Your First Session:

Having them prior to your first session can be incredibly beneficial so Carla knows what to expect.

We will never share any pictures or videos without your written consent.

Intake Form

An intake form is required before your first appointment

Mother's Information

Father's Information

Names and Ages of Others Living in the Household

General Information

Child's Birth History

Medical History

Digestion

Child Care Information

Previous Therapy Interventions

Other Physicians & Surgeons involved in child's care with address & phone

Complementary or Alternative Healthcare Professionals Consulted

Developmental History

Baby Devices Used

Manipulation

Toileting

Communication

Feeding

Activities

Photo/Video Release (Optional)

Connecting with Other Families (Optional)

Upload Photos / Video

After Submitting this Form - A Link to Send Photos/Videos will be displayed

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Sterling, Virginia

(703) 598-3168

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