Parent Name
*
Phone
Email
*
Preferred method of communication
*
Text
Email
Phone
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Child Information
Child Name
*
Date of birth
*
Gender
*
M
F
Primary Reason for Reaching Out
What are the main reasons you're seeking care?
*
Digestive issues (constipation, reflux, abdominal pain)
ADHD, ASD support, behavioral or emotional regulation
Chronic illness (asthma, autoimmune concerns, allergies, eczema)
Sleep problems
Frequent infections
Nutrition concerns
Growth or developmental concerns
PANS/PANDAS
Mood or anxiety concerns
Other complex or chronic symptoms
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What else would you like the provider to know?