New client form for children | Return to Source Wellbeing - Kinesiology & Intuitive Healing

Please complete this form for your child and click "Submit" at the bottom of the page. There's no need to print the form out, unless you'd like to keep a copy for yourself.

Contact information

All client information is private and confidential.

Parent's name*

First Middle Last

Child's name*

First Middle Last

Please write their name as it appears on their birth certificate (incl. middle names).

Address*

Street Address Address Line 2 City State Postcode Country

Phone*

Email*

Personal Details

Gender*

Female
Male
Non-binary

D.O.B.*

Age*

Country of birth*

Referred by

Siblings (name, age, gender):

Does your child experience anxiety, depression or chronic stress?*

No
Yes - Anxiety
Yes - Depression
Yes - Chronic stress

If yes, please indicate which condition.

Briefly describe your child's wellbeing problem(s)*

How long have they had the problem(s)?*

Do you regard their wellbeing problem(s) to be:*

Severe
Quite severe
Moderate
Mild

Do they have any other chronic or recurring illnesses, diseases or problems?

ie. rashes, allergies, sleeplessness/insomnia, shortness of breath, migraines, constipation, infections, coughs, colds, asthma, cancer, heart disease, ulcers, etc...

Past accidents or surgeries (incl. date and age):

e.g. car accidents, broken bones, falls, sprains, concussions, dental surgery, cesareans, etc.

Please list any medication and/or herbal, nutritional supplements they're currently taking.

i.e. pharmaceutical medicines, vitamins, supplements, herbal medication, homeopathics or flower essences, etc...

Do they have (or you suspect) they have any allergies, food sensitivities or intolerances? If yes, please describe.

Diet & Lifestyle

Food preferences*

Meat & veg
Vegetarian
Vegan
Macrobiotic
High protein
Wheat free
Gluten free
Dairy free
Other

Briefly explain your daily/weekly intake of sugar, tea, herbal tea:

What is their daily water intake?*

2+ Litres
1 Litre
500ml
Less

Are their bowel movements:

Daily
Less than daily

How often do they exercise?

Daily
Weekly (2-4x)
Occasionally
Never

On a scale of 1-10 what is their daily energy level?

On a scale of 1-10 how would you rate their sleep quality?

Select all that relate to their sleeping habits*

On a scale of 1-10 how would you rate their current stress levels?

Cause(s) of stress in their life:

Current health care

Have they had Kinesiology before?*

Yes
No

If yes, please explain how often, purpose of the sessions etc.

Do they have a history of trauma and/or abuse?*

Yes
No

Have they been diagnosed with a mental health issue?*

Yes
No

If yes, please include details of the diagnosis.

Are they on a Mental Health Plan*

Yes
No

If yes, please include details like when they entered the plan & what treatment they're currently receiving. Please also provide the name and contact number of their mental health care practitioner.

Are they working with other other health care practitioners?*

E.g. Naturopath, Osteopath, Chiropractor, Counselor etc

Yes
No

Personal health concerns

Please select the issues that relate to you:

Please list any of the above that you would specifically like to deal with:

Is there anything else you want me to know?

Would you like to sign up to my mailing list?*

Yes please!
No thank you
I've already subscribed

I newsletters about 1-2 per month. No spamming, I promise!

Terms of Service

Before submitting your client intake form, please read the Terms of Service below.

Privacy
All information collected in this form and discussed in your Kinesiology session will remain confidential at all times.
The healing process
Please be aware that recovering from a chronic, complex illness requires a commitment of time, energy, and resources. Progress can often be cyclical rather than linear. You may experience periods throughout your treatment where your improvement plateaus. This is normal. It is important to continue treatment through these cycles to achieve a successful outcome.
Other possible costs in addition to your session: Liquid Crystals and/or nutritional supplements
I'm also a Liquid Crystals practitioner, and will often prescribe a Liquid Crystals remedy to support your Kinesiology session. Remedies are either $10-$15 for a Single crystal or $30 for a Trinity. Postage and handling (if required) is $10.
If your body tests up as needing nutritional supplement support, I do keep some stock on hand, and/or I can order supplements on your behalf. Supplement prices vary.
It's always your choice as to whether or not you'd like a recommended Liquid Crystals remedy or nutritional supplement.
Cancellation/No-Show Policy
I require 24 hours notice should you elect to cancel or reschedule an appointment. If you fail to attend a scheduled appointment without notice then the full cost of the session will be charged.
Repeated last-minute reschedules
If you find yourself in a pattern of rescheduling, even when providing 24 hours notice, this will also be considered a cancellation/no-show and the full cost of the session will be charged.
Agreement to Terms of Service
By filling out the required information, you agree that you have read and accept the above terms of service.

Agreement*

I agree to the above Terms of Service