Confidential Consultation Information Form
Thank you for your interest in my work! To save us some time during our chat, please fill out this form within 24 hours before our scheduled appointment. That way we can focus on your current goals and next steps for moving things forward:)
Today's Date
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Full Name
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First Name
Last Name
Day Phone
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Country Code
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Area Code
Phone Number
Mobile Number
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Skype Id (if applicable)
Email address
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Street Address 1
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Street Address 2
City/Town
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State
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Zip Code
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Country
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Child's Name
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Child's Date of Birth
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Would you like to receive updates through our online newsletter?
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Are you looking for an Integrative Autism Specialist in your area? (If yes, please continue to fill out the form so I can refer you to someone I think will be the best fit. I will still contact you personally to hear more about your situation.)
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How did you hear about April's work?
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Referral by friend or professional
Facebook
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LinkedIn
Other
If "Other", please specify:
Why are you contacting April at this time?
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Please tell me what you know about the programs I offer.
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Please describe your journey with your child up to this point. What is working and what is not working?
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What are you looking for in a coach/consultant for your family?
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Please list all the members of your child's current team, including therapists, babysitters, medical professionals, etc.
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Please tell me what kind of therapies you have in place to help you manage your child's program and your family's quality of life.
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What kind of support are you inquiring about? Please check all that apply
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Online Training Courses
Transcend Autism Academy
Private Consultation (all ages)
Spiritual Coaching/Healing Sessions
I'd like a referral to an Integrative Autism Specialist in my area
I just want to chat and learn more about support options
Please tell me how your child's developmental differences are impacting you and your family on a day to day basis.
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What is your immediate priority for the next 3-6 months?
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How urgent is it that you get help for your child at this point in time? On a scale of 1 to 10, 1 = no immediate need for support, 10= crisis, we need help immediately
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Are you currently willing to work intensively with a consultant to create a customized program for your child? Why or why not? (timing, not urgent enough, etc)
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How important is it to you to get to the root of your child's challenges so he or she can attain the highest quality of life possible?
Why are you contacting April at this time?
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If you do not successfully address your child's challenges what do you think his or her future may be like? How will he or she feel on a day to day basis? How will you feel?
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What else is important for me to know when considering support options for your child and family?
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