First Name *

Last Name *

Phone *

Email *

We will send reminders of the event. What is your preferred communication? *

Email Reminders

Text Reminders

Both Email & Text

How did you hear about our workshop? *

Friend / Family

Facebook

Instagram

Flyer

Other

Are you seeking hope, answers, and healing for *

Your Child / Children

Grandchild

Family Member

Friend

Other

Will anyone else be attending the workshop with you? *

Yes

No

Please tell us your child's / children's age(s) *

Were there any fertility challenges? *

Yes

No

Unsure

Was there any extra stress or challenges during pregnancy? *

Yes

No

Unsure

Was intervention needed during the birth process? *

Yes

No

Unsure

What interventions were needed? *

Epidural

Induction

Vacuum

Forceps

C-Section

Other

None

Has your child(ren) experienced any of the following? *

Frequently Sick

Ear Infections

Needing Tubes / Has Tubes

Frequent Strep

Allergies

Asthma

Eczema

Fatigue

Digestive Issues

Other

None

During infancy, did your child(ren) experience any of the following? *

Difficulty Eating / Latching

Colic

Sleep

Reflux

Constipation

Torticollis

Arching / Stiffness

RSV

Croup

Other

None

Has your child(ren) been on antibiotics before? *

Yes

No

Unsure

Has your child(ren) experienced any of the following?  *

Sleep Challenges

Mood / Emotional Regulation

Developmental Delays

Seizures

Bedwetting

Sensory Concerns

Speech Concerns

Behavioral Concerns

Other

None

Has your child(ren) been diagnosed with any of the following? *

Anxiety

ADHD

Autism (ASD)

Sensory Processing Disorder (SPD)

Bipolar Disorder

DMDD

ODD

OCD

Other

None

Does your child(ren) have any autoimmune conditions? *

Celiac Disease

Type 1 Diabetes

Juvenile Rheumatoid Arthritis

PANDAS

Other

None

What have you tried for your child(ren)'s current challenges? *

Medication

Supplements

Chiropractic Care

Home Changes

Mental Health Therapy

Physical Therapy

Surgery

Other

None