CHILD INTAKE FORM

Thanks for taking the time to fill out this form for your child. It helps me get a clearer picture of what your child is experiencing, what support they might need, and how we can work together to help them feel more balanced and at ease. Everything you share is kept completely confidential. Kinesiology gently supports the body and mind, and your insights as a parent are an important part of making the session as helpful as possible.

  • BY SUBMITTING THE ABOVE FORM, YOU ACKNOWLEDGE AND AGREE TO THE TERMS BELOW. BY CLICKING "SUBMIT" YOU ARE CONFIRMING THAT YOUR HAVE READ AND ACCEPTED THE TERMS.

    1. DIAGNOSIS: If you desire diagnosis for a symptom we will recommend you seek the services of an allied health care provider. By law Josie Holt Kinesiology may not provide a medical diagnosis or recommend discontinuance. of medically prescribed treatments.

    2. SERVICES: The provision of Josie Holt Kinesiology services entails the collection and recording of personal information relevant to your current situation. This information is a necessary part of your assessment and treatment protocol.

    3. ACCESS: Any information gathered, recorded, and filed is available upon request. Confidentiality: All personal information gathered during the session shall remain confidential and secure except if:

    1.It is subpoenaed by a court, or
    2.Prior approval has been obtained to: Provide a written report to another professional or agency. e.g. a GP or a solicitor, or Discuss the material with another person. e.g. a parent or employer.

    4. CANCELLATION POLICY: The appointment time reserved for you is exclusively for you. We require a 24-hours notice of cancellation. If you must cancel, or reschedule, an appointment due to an emergency, please notify us as soon as possible, we understand that ͚things do happen. If you do cancel with less than 24 hours notice, “full payment“ for the session is required. Thank you for your consideration and understanding. Full payment is expected via PAYID within 72 hours of the cancelled appointment.

    5. NO SHOW: In the event of a no call/no show situation, the client will be charged for the full session cost. Thank you for your consideration and understanding. Full payment is expected via PAYID within 72 hours of the cancelled appointment.