Child Intake Form - Little Mountain Homeopathy

After you have booked the initial classical homeopathic consultation, the guardian of new child or teen clients (0-17 years) must fill out the intake form before the consultation.

Child Intake FormDownload

Please download the intake form above and bring it to your appointment, or email the completed form to LMhomeopath@gmail.com.

Guardians can also complete form on the website by filling out the form below:

Dear Parent,

Welcome to my office. This questionnaire will help you to organize your thoughts for our initial meeting. Clients find the timeline especially useful. I am the only person who will review this survey and your confidentiality is strictly maintained. If you have questions or concerns about this questionnaire, please contact the office and I will help you to decide how best to solve the issue.

Please enable JavaScript in your browser to complete this form.

Child's Name

First

Last

Gender

Mother's Name

First

Last

Father's Name

First

Last

Telephone Number

Street Address

City

Please to that

Province or State

Postal Code or Zip Code

Country

Child's Date of Birth

Number of Siblings and Details (Age, Sex)

Would you like to receive my newsletter (sent a few times per year)

Who referred you to this clinic?

ACKNOWLEDGEMENT (guardian please read, then initial and date to indicate that you agree)

Sonya McLeod uses non-invasive methods for the assessment of bodily dysfunction, and homeopathy for their correction. In order to avoid any confusion or misunderstanding, she requests that all clients read and acknowledge the following: •That you understand that Sonya McLeod works within the homeopathic scope of practice, is not a medical doctor, and employs some methods which are not orthodox medical practice at this time. •That you understand that care here and/or referral to other health professionals is based upon the assessment revealed through personal history and interview, physical assessment, and laboratory testing. •That you understand homeopathic care is not generally covered under MSP at the present time and, therefore, you are responsible for any fees incurred while under treatment. Homeopathic care is covered under many private insurance plans and appropriate documentation will be provided to your insurer upon request. •That you are here as a client and are not attending this clinic for any other reason without making your intention known. Please be informed that you are required to give at least 1 business day notice in case you need to cancel or reschedule any appointment, including the initial one. Otherwise you will be charged for the missed appointment. Your consideration is greatly appreciated in this matter.

CONSENT FOR CARE (guardian please read, then initial and date to indicate that you agree)

Sonya McLeod will take a thorough case history. It is very important that you inform Sonya of any disease process that you are suffering from and any supplements/medications/over the counter drugs that you are currently taking. Please advise immediately if you suspect you are pregnant, or if breast-feeding. There are some health risks associated with the use of homeopathic remedies, herbs and supplements. These include but are not limited to the following: • Homeopathic remedies may occasionally result in the aggravation of pre-existing symptoms. When this occurs, the duration is usually short. • Homeopathic remedies may stimulate healing or detoxification reactions, which may include loose stools, increased perspiration, skin eruptions and nasal discharges, among others. These reactions are relatively uncommon and normally pass within a few hours to days. • Nutritional supplements sometimes cause stomach discomfort. Niacin-containing supplements may cause skin flushing and itching. • Rarely, individuals may experience allergic reactions to certain supplements and herbs. Please advise Sonya immediately if you think that you have experienced an allergic reaction. • Please let Sonya know immediately should you experience any negative side-effects from any of your homeopathic and wellness care. Important points to note: • Sonya McLeod does not guarantee treatment results. • A record will be kept of the health services provided to you. This record will be kept confidential and will not be released to others without your consent, unless required by law. You are entitled to a copy of your records at any time and to transfer of your records to another practitioner if desired. • Sonya will explain to you the exact nature of any treatment provided and will answer any questions you may have to the best of her ability. • You are free to withdraw your consent and to discontinue care at any time.

CONFIDENTIAL CLIENT INFORMATION. What is your main reason your child is attending this office? If this involves a specific health condition, please describe it in detail. In your own words, list the very first time that you noticed this condition and describe carefully any factors that you suspect may have played a role on its onset and development.

If this is a chronic complaint how long has your child had it?

Who diagnosed your child's condition and when was the diagnosis made?

What specialists have been seen and when?

How has this complaint been treated until now, and what results have been obtained to date?

What other objectives do you have as far as your child's health is concerned?

How long has it been since your child was totally well?

Please list the 5 most significant, stressful events in your child's life, from the most recent to the most distant. Are any of these situations continuing to impact your child's life? If so, please indicate these clearly.

Is your child currently working with a professional counselor, psychologist, social worker, or other therapist? Please provide details

Has your child had homeopathic care before? Please provide details:

Please draw a timeline of all major events in your child's life. This will assist me to assess your present health problems. Please indicate in chronological order all accidents, illnesses, hospitalizations, surgery, broken bones, sprains, falls, traumatic and emotional events, major changes in your child's life up to this point in time. I would also like to know when your child had vaccinations, when they started school, changed schools, graduated, failed, etc. Major life events and traumas can have long-lasting effects on health. You can start with when your child was born, or some people find it easier to begin at their present age and work backwards, it is your choice.

FAMILY HEALTH HISTORY Please indicate below which of the following ailments, or any other ailments, have affected your child's relatives. Include any peculiar characteristic of relatives who are similar to your child in any way. Alcoholism, Asthma, Epilepsy, Heart Disease, Paralysis, Syphilis, Allergies, Cancer, Gonorrhoea, Hypertension, Pneumonia, Thyroid, Alzheimer's, Depression, Gout, Kidney Disease, Skin Disorder, Arthritis, Diabetes, Hay Fever, Mental Illness, Digestive Disorders, Tuberculosis