New Client Brain Integration Technique Paperwork

New Client Appointment Checklist

Complete and submit form below

No makeup, perfume, lotions, or deodorants

Drink plenty of water prior to your session

Do not come hungry; be sure to eat prior to your session

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These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

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Please understand the importance of keeping your appointments. We do have a 24 hour cancellation policy that is strictly enforced.

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Please contact our Client Advocate if you have any questions or need additional information.

New Client Form

CLIENT INFORMATION:

Name: *

Today's Date: *

Home Phone Number:

Cell Phone Number: *

Email: *

Best way to reach you:

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate: *

Age: *

Gender:

Referred by:

Are you currently a client of The Well of Life Center? *

If yes, who is your clinician?

Occupation: *

Employer:

Marital Status: *

Name of Spouse:

List names of children/siblings, age, sex and any concerns in the area below.

In Case of Emergency, please contact:

Emergency Contact Name: *

Emergency Contact Phone Number: *

Relationship: *

Please provide details if any or all of the following applies to this client:

Adopted? *

Other explanation:

Reason you are here:

Previous treatments for this complaint:

The following questions are part of the background necessary to evaluate your learning problems. A number of factors involved with the prenatal, birth, and early postnatal periods are sometimes associated with learning difficulties. Please briefly indicate if any of the listed items below apply and note any that are not included in this list.

1. Mother of Client

Sickness of any kind

If yes, describe:

Anything requiring medical attention of any kind during or as a result of pregnancy or birth?

If yes, describe:

2. Client's Birth

Any difficulty in the birthing process? (e.g. cord around neck, posterior presentation, forceps, oxygen problems at birth, baby bluish)

If yes, describe:

Fetal distress at birth?

Comments:

Was your baby removed for a period before presentation to you?

If yes, for how long?

Was there a period of extended separation, e.g. premature?

Comments:

Medical treatment of any kind needed?

If yes, describe:

Any other problems?

If yes, describe:

3. Are you currently under the care of a physician, therapist, or other health care professional?

If yes, please list name(s) and date(s) of last visit:

4. Current medications/drugs being taken:

5. Nutritional supplements you are taking:

6. Do you smoke, drink alcohol, or consume any other substances? If yes, indicate how much.

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Cigarettes:

Alcohol:

Other substances:

7. Have you suffered any serious childhood diseases, had any operations, or other medical problems?

8. Have you ever been knocked unconscious? If yes, for how long and under what circumstances?

9. Have you ever been in a car accident? If yes, did you get whiplash? (describe)

10. Have you ever had an epileptic fit? If yes, describe.

11. Have you ever suffered febrile seizures (high temperature induced fits or seizures), especially between 8 months and 3 years? If yes, describe.

12. Do you suffer from asthma? Taking medication for it? Which and how often?

13. When did you start to crawl? Did you crawl normally - opposite hand and knee - or did you tend to scoot along on your bum or drag/extend one leg?

14. When did you start talking? Was there any verbal language delay? If so, how long?

15. Any household pets or other animals you or your family members are in close contact with?

16. How would you describe your mood on a day-to-day basis?

17. Any other facts or information that you feel are relevant?

MEDICAL HISTORY

Most recent physical examination:

Purpose:

Other:

Current medical treatment, impending surgery, genetic/development delay, or other treatment?

List all drugs you are currently taking and their purpose:

PLEASE ADVISE IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

BRAIN INTEGRATION TECHNIQUE BEHAVOIRAL CHECKLIST

Phobias/fears

Explain:

Speech difficulties

Explain:

TMJ/Orthodontics

Explain:

Other:

Explain:

Agreement and Release of Liability: *

Please click HERE to read our Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of Agreement and Release of Liability.

Phone

New Client Brain Integration Technique Paperwork

New Client Appointment Checklist

These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

Please understand the importance of keeping your appointments. We do have a 24 hour cancellation policy that is strictly enforced.

Please contact our Client Advocate if you have any questions or need additional information.

New Client Form

CLIENT INFORMATION:

In Case of Emergency, please contact:

Please provide details if any or all of the following applies to this client:

1. Mother of Client

2. Client's Birth

MEDICAL HISTORY

BRAIN INTEGRATION TECHNIQUE BEHAVOIRAL CHECKLIST

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