Parent Child Intake Form Please fill out this form at least one day before your discovery session with Focused Healthy Kids. Thank you! Parent Child Intake Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Parent Full Name * Child's 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 What is the challenge you would like to resolve? How has this issue affected you? Work? Social life? Relationships?: How has this affected the child with the issue? Behavior? Emotions? School? Sports? Friends? Social Life?: How has this affected the other child(ren) in the family? Behavior? Emotions? School? Sports? Friends? Social Life?: Was there a particular incident that triggered this issue? Please describe. 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.
