Reflex Integration &
Neurodevelopmental movement therapy
Intake form: Child
Your full name *
Your phone number *
Your email address *
Your child's full name and date of birth *
What are your main concerns? *
Were there any health complications during pregnancy?
What was your child's birth weight?
In what week of gestation was your child born?
What were the circumstances of birth and delivery? Forceps, C-section, prolonged, dystocia, emergency, etc.?
Any other problems after birth like surgery, jaundice, medications, feeding issues, etc.?
Was your child breastfed?
During the first 18 months of life, did your child experience high fever, convulsions, vaccine reactions, feeding problems, frequent ear infections, or any other medical/health issue?
Did your child scream a lot as a baby or have trouble sleeping?
When did your child begin walking?
When did your child begin speaking?
Was your child sluggish or inactive as a baby/toddler?
Did your child crawl on hands and knees?
Did one leg trail behind when crawling?
Did your child go through a defiant stage (around 2-3 years of age)?
Has your child sustained a head injury or concussion?
Does your child have allergies? If so, to what?
Did your child experience delay or difficulty in left/right hand preference?
Does your child wear glasses or have any vision issues?
Does your child have speech issues?
How well does your child cope in a school or daycare environment?
Would you consider your child clumbsy and uncoordinated? How so?
Does your child have difficulty holding up his/her head? (Slouching, putting chin in hand when sitting, etc.)
Does your child have any difficulty wearing tight clothing or with the tags inside clothing?
Does your child have fine motor difficulty like handwriting, buttoning, tying shoes, etc.?
Does your child have gross motor challenges like riding a bike, swimming, jumping, doing somersaults, etc.?
Does your child have poor balance?
Does your child fluctuate between too active and exhaustion?
Is your child hypersensitive? (To sound, light, touch?)
Does your child walk on his/her toes?
Is your child highly emotionally reactive?
Is your child a "picky" eater?
Is your child physically or relationally timid?
Did your child wet the bed beyond five years of age?
Is there anything else you would like to add?