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Intake Form
Thank you for taking the time to fill out the following questions. Please submit the completed version back to me as soon as you can. All your information will be kept confidential.
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Name
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Your answer
What is your main parenting concern?
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Your answer
What have you done in the past to work on this condition? (include both alternative and traditional modalities.)
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Your answer
What has proven effective?
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Your answer
What is your family's current diet like? Please be specific; list breakfast, lunch, dinner, and snacks, as well as the times you eat.
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Your answer
What would you like to see change inn the next 30 days from now? How about 90 days from now? How would you feel if you got this result?
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Your answer
What obstacles, challenges, and struggles do you come up with regarding the life of a parent
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Your answer
What do you hope to get out of our time together?
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Your answer
What are 5 things you LOVE about your life?
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Your answer
Do you smoke?
Yes
No
Clear selection
On a scale of 1-10, how ready are you to quit?
Not at all ready
1
2
3
4
5
6
7
8
9
10
Already Starting to Quit
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