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

Mother's Information

Father's Information

Names and Ages of Others Living in the Household

General Information

Child's Birth History

Some description about this section

Medical History


Child Care Information

Previous Therapy Interventions

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

Complementary or Alternative Healthcare Professionals Consulted

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

Developmental History

Please note approximate age in months for each action

Baby Devices Used

Age in months & estimated hours per day


Age in months


Age in months


Age in months


Age in months


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.

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.

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.


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

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