Individual Intake Form Please fill out this form at least one day before your discovery session with Focused Healthy Kids. Thank you! Individual Intake Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Full Name * Address * City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Email * Home Phone * Cell Phone I am: * SingleSingle ParentMarried no childrenMarried with childrenDivorced no childrenDivorced with childrenWidow no childrenWidow with children What is the challenge you would like to resolve? Was there a particular incident that triggered this issue? Please describe. How has this issue affected you? Work? Social life? Relationships?: Can you describe what a good outcome would look like? Feel like? What is 10 + 2 = * This simple equation answer helps to prevent spam. Simply put the answer to the math problem in the box above before submitting this form.
