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SERVICES
ABOUT
eBOOK
FOR CLIENTS
- ADULT INTAKE FORM
- CHILD INTAKE FORM

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HOME
SERVICES
ABOUT
eBOOK
FOR CLIENTS
- ADULT INTAKE FORM
- CHILD INTAKE FORM

HOME
SERVICES
ABOUT
eBOOK
FOR CLIENTS
- ADULT INTAKE FORM
- CHILD INTAKE FORM

Intake Form for Youth Clients

Anchor 1

Begin your Child's Journey with Holly

If your child has not had a session with Holly previously, please complete & submit the New Client Intake Form below

THIS FORM SHOULD BE COMPLETED FOR YOUR (MINOR) CHILD & SUBMITTED BY A PARENT/GUARDIAN

Child Intake Form

NEW CLIENT INTAKE FORM FOR CHILDREN (UNDER 18)

FOR BODYWORK AND/OR WELLNESS SERVICES WITH HOLLIANNE DELVALLE / HOLLYSTIC ALCHEMY

YOUR CHILD'S INFO

First name*

Last name*

Child's Birth Date*

Month

Day

Year

PARENT / ADULT GUARDIAN INFO

Adult Full Name*

Phone*

Email*

Multi-line address

Country/Region

Address

City

Zip / Postal code

YOUR EMERGENCY CONTACT

EMERGENCY CONTACT: First & Last Name*

EMERGENCY CONTACT: Phone Number*

A LITTLE BACKGROUND

Has your child received CranioSacral Therapy, body work, or massage therapy before?*

Yes

No

If yes, what kinds of bodywork have they had experience with & when?

HEALTH HISTORY

Does your child exercise regularly?*

Yes

No

If yes, how many hours per week (in total) do they intentionally move their body?

Is your child on any medication?*

Yes

No

If you answered YES, which medications are they currently taking?

REGARDING THIS CHILD'S PREGNANCY & BIRTH

Was the pregnancy with this child planned?*

Yes

No

How was Mother and Father’s initial reaction to the pregnancy?

Did that change as the pregnancy went on?

Yes

No

How was Mother’s physical health throughout pregnancy?*

What what the child's Gestational Age at Birth?*

Did the birth go as “planned”?*

Yes

No

If you answered "no", explain:

Baby's birth?

Vaginal birth

C-Section

Any Medications or Interventions used?

Yes

No

Any Birth Trauma experienced that you know of?

Yes

No known birth trauma

If Boy, were they circumcised?

Yes

No

Any Vaccines or medications administered?*

Yes (all/some)

No (none)

Optional: If you answered "yes" or "no" but want to add anything regarding vaccines or medications administered to your child, you can elaborate below

SLEEP PATTERNS

When sleeping do they: snore, grind teeth, and/or mouth-breathe?*

Yes

No

How is sleep?*

What position does the baby/child typically sleep in?*

Are/were they Swaddled?*

Yes

No

ORAL, PHYSICAL & DEVELOPMENTAL CONSIDERATIONS

Did baby crawl?*

Yes

No

Crawling: If "yes," for how long?

CHECK ANY/ALL THAT APPLY ("YES"):

Torticollis or Plagiocephaly?

Any Oral Ties Assessed/Addressed?

Any digestion or BM concerns?

Any food sensitivities? ARFID?

Any Sensory Processing, ASD, or ADHD?

HOW DO WE KNOW EACH OTHER?

How did you hear about Hollystic Alchemy?*

If you met Holly at an event, or through a friend, or as a referral, let me know who to thank for the introduction!

PLEASE SIGN & DATE

Full Name of Parent/Adult Guardian*

Adult Signature*

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Today's Date*

Month

Day

Year

Note: your personal information will never be shared, and is use to inform your session & for Holly's professional use only

528 48th Street Court East

Bradenton, FL 34208

hollysticalchemy@gmail.com

Holistic healing in SRQ ... and beyond!

Lic #MM46204 | #MA102333

✶ CranioSacral Therapy

✶ Manual Lymphatic Drainage

✶ Medicupping ✶ EFT Tapping

✶ Primitive Reflex Assessments

✶ Bioresonant Feedback Scans

✶ Inner Voice Scans

© HOLLYSTIC ALCHEMY by Holly DelValle 2023 - 2025

DESIGNED BY ANNIE LUCID

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