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Divyam Mind Guiding Academy: Intake Form
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* Indicates required question
Email
*
Your email
Contact Number/ फ़ोन नंबर
*
Your answer
Name of the Child/ बच्चे का नाम
*
Your answer
Age/ उम्र
*
Your answer
Gender/ लिंग
*
Male
Female
Other:
Address/ घर का पता
*
Your answer
Goes to School?/ स्कूल जाता है?
*
Yes
No
Name of the Parents/ माता-पिता का नाम (Father, Mother)
*
Your answer
Occupation/ काम (Father, Mother)
*
Your answer
Parent Concerns / Child Problems (बच्चे की समस्या)
*
aggression
has few friends
has no friends
overactivity
language difficulties
toilet training
preoccupations
temper tantrums
biting
hitting
self-injury
sleep problems
sleeps in parents’ bed
has nightmares
nervousness
argumentative
easily distracted
self-help skills
won’t take baths
appetite/food selections
eats things that aren’t food
wets the bed
pulls out own hair
inattentive
school adjustment
cruel to animals
inappropriate sexual behavior
motor skills
depressed or anxious
muscle tone
self-stimulatory behaviors: rocking, spinning, flapping hands, visual scrutiny
Other:
Required
Looking for: (Choose as many as Applicable)
*
Parent Coaching
Required
Where did you find out about Divyam? दिव्यम के बारे में आपको कहां पता चला?
*
Your answer
Comments/ Queries (Optional) समीक्षा
Your answer
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