Brain Integration

Brain Integration Intake Form

Please complete this form within 48 hours of scheduling your appointment. Fill out one form per client. Parents or guardians sign for clients under 18.

Client's First Name *

Client's Last Name *

Date of Scheduled Appointment *

Client's Age *

Client's Date of Birth *

Parent / Guardian Name (if client is under 18)

Best Phone Number *

Street Address *

City *

State *

I agree to answer every question as honestly as I can. I understand that the accuracy of my answers directly affects the quality of the session.I understand that at least 1 week's notice is required to reschedule or cancel an appointment. Late cancellations may be subject to a fee.I understand that Trevor Dimick is not a licensed medical or mental health professional. Brain Integration is not a medical treatment and is not intended to diagnose, treat, cure, or prevent any disease or disorder.

ADHD / ADDAllergiesAnxietyAuditory Processing DisorderBipolar DisorderConcussionDyslexiaDepressionOCDPTSDTBIOther

ImpulsivenessDisorganizationPoor time managementTrouble multitaskingDifficulty focusingFidgeting or restlessnessTrouble completing tasksCareless mistakesForgetfulness in daily activitiesLosing things frequentlyEasily distractedDifficulty listeningFailing to follow through on instructionsAvoiding tasks requiring sustained mental effortTalking excessivelyBlurting out answersDifficulty waiting turnsInterrupting othersMood swingsHot temperLow frustration toleranceDifficulty sitting stillHyperfocus on preferred tasksPoor planningLow self-esteemRelationship difficultiesSubstance misuse

Late talkingSlow learning new wordsDifficulty rhymingTrouble readingWord reversals (b/d, p/q)Letter reversalsDifficulty spellingReading below grade levelPoor handwritingAvoiding reading aloudDifficulty following multi-step instructions

Difficulty locating the source of soundsDifficulty understanding speech in noisy environmentsFrequently asking for repetitionMishearing wordsDifficulty following verbal instructionsShort auditory attention spanDifficulty processing rapid speechAcademic difficultiesLanguage delaysPoor musical abilityDifficulty learning a foreign languageDifficulty with phonics

Persistent sadnessHopelessnessLoss of interest or pleasureFatigue or low energySleep disturbances (too much or too little)Changes in appetite or weightDifficulty concentratingFeelings of worthlessnessExcessive guiltIrritabilitySlowed thinking or movementPhysical aches without clear causeSocial withdrawalCrying spellsDifficulty making decisionsNegative self-talkLoss of motivationSuicidal thoughtsThoughts of deathInability to experience pleasure

Excessive worryNervousness or restlessnessIncreased heart rateRapid breathingSweatingTremblingFeeling of impending dangerDifficulty concentratingTrouble sleepingGastrointestinal problemsAvoiding anxiety-triggering situationsMuscle tensionFatigueIrritabilityPanic attacksPhobiasSocial anxietyPerfectionismFear of losing control

Frequent anger outburstsArguing with adults or authority figuresRefusing to comply with rulesDeliberately annoying othersBlaming others for mistakesEasily annoyedSpiteful or vindictive behaviorUsing harsh or unkind wordsActive defianceQuestioning rulesRevenge-seekingPersistent negativity

Extreme resistance to everyday demandsUsing social strategies to avoid demandsAppearing comfortable socially but struggling internallyMood swings and impulsivityComfortable in role-play and fantasyObsessive behavior focused on other people

Playing Video Games 0 hrs/day

0 hrs12 hrs

Watching YouTube 0 hrs/day

0 hrs12 hrs

On Social Media 0 hrs/day

0 hrs12 hrs

On Computer for School / Work 0 hrs/day

0 hrs12 hrs

Other Brain or Health Diagnoses and Symptoms

Current Medications or Supplements

I confirm that all information provided in this form is accurate and complete to the best of my knowledge.I understand and accept full financial responsibility for the services rendered.

Date *

Signature (type your full name) *