Founding Families

Application Form

First Name *

Last Name

Phone *

Email *

Address

Street Address *

City *

State *

Country *

Postal code *

Child's First Name *

Child's Age *

Child's Gender *

If Other, please describe.

Autism Diagnosis *

Is your Child Potty Trained? *

Is your Child Aggressive? *

Is Your Child Non-Verbal? *

Other (Please specify):

Does your child have gut issues? *

Are there any digestive issues such as constipation, diarrhea, irritable bowel? Please describe

Is your child currently on any recurring medications? If yes, please describe

Can you afford to invest $500 per month on interventions we recommend based on the results of the blood tests (not bought from us)? *

Medical Conditions: Are there any other medical conditions or diagnoses? *

Describe a typical breakfast for your child *

Please describe a typical lunch for your child. *

Please describe a typical dinner for your child. *

Please describe a typical snack for your child. *

Is your child currently taking any supplements or vitamins? If so, what are they?

How often does your child eat restaurant/fast food each week on average? *

What do they typically eat when eating at a restaurant or drive-thru? *

Does your child get up at the same time every morning? *

Allergies and Sensitivities: Does your child have any known food allergies or sensitivities? *

Eating Challenges: Are there any specific challenges related to eating or food that your child faces? *

Behavioral Patterns: Have you noticed any behavioral changes related to certain foods? *

Has your child received all of their childhood vaccines? Please explain. *

Does your child have a consistent bedtime routine and what time does he/she fall asleep? *

How much time does your child spend on phone/tablet per day? *

How much time does your child spend on the computer per day? *

How much time does your child spend outside per day? *

Are there any sports that your child participates in?

I consent to having NeuroSynergetics collect, read, and make an assessment of my qualification for the Founding Families program. This includes contacting me to collect any additional information to make an informed decision on our family's ability and willingness to participate in the program.

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