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Child Inquiry Form
Please note that all fields followed by an asterisk must be filled in.
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Child's Date of Birth
What is your child currently able to do on his / her own?
If selected "other" above, please describe:
Has your child had any serious injuries / operations?
Current Medications / Supplements Your Child Is Taking
What therapies does your child receive at this time? traditional or alternative
How often do they receive these therapies and what are the current goals?
If so, please describe which ones and how often they are used? (baby swings, jumping devices, special chairs, walkers, standers, AFO’s, braces, splints, wheelchair, etc.)
How much floor time does your child have each day?
What sort of activities does your child like and dislike?What sort of toys and activities does your child like and dislike?
How would you describe your child’s nature? * quiet, inquisitive, restless, anxious, playful, etc.
Is there anything else you would like to add to help me better understand your child?
What short term goals would you, as a parent, like to see your child accomplish in the upcoming months?
How did you hear about Anat Baniel Method / Neuroness?
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