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Intake Form
Please fill out this form to the best of your ability.
Child's Name
Child’s Date of Birth
Parent/Guardian Name (s)
Address
Phone Number
Primary Concerns/Goals
Birth/Medical History
Does your child have a diagnosis? Please list all if applicable:
Pediatrician Information
Is your child currently under medical care from specialists or receiving therapy or additional services:
List all medications/supplements:
List any accidents, injuries and surgeries (with dates):
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