Brain Integration Form Brain Integration Intake Form You may complete this form now online or on paper the morning of your appointment. Please enable JavaScript in your browser to complete this form.Client's Name *FirstLastDate of Client's Scheduled Appointment *Client's Parent's Name (clients under 18 years of age)FirstLastClient's Age *Client's Date of Birth *Best Email (Parent's Email for Clients Under 18 Year Old) *Street Address *City *State *Zip Code *Best Phone Number (Parent's Phone Number for Clients Under 18 Years Old) *Diagnosis; Professional or Self (Please check all that apply)ADHD/ADDAllergiesAnxietyAuditory Processing DisorderBipolar DisorderConcussionDyslexiaDepressionOCDPTSDTBIOtherCheck All That ApplyCommon Symptoms of ADHD Symptoms (Please check all that apply)ImpulsivenessDisorganized and problems prioritizingPoor time management skillsProblems focusing on a taskTrouble multitaskingExcessive activity or restlessnessPoor planning skillsLow frustration toleranceFrequent mood swingsProblems following through and completing tasksHot temperFidget, tap hands or feet, or squirm in the seatDifficulty staying seated in the classroom/meetingsAlways on the go, in constant motionInappropriate running around or climbTrouble playing or doing activities quietlyTalk too muchBlurts out answers, interrupts other peopleHave difficulty waiting for their turnIntrudes on others' conversations, games, or activitiesFails to pay close attention to detailsMake careless mistakes at work or schoolTrouble staying on task or focused during playAppears not to listen, even when spoken to directlyDifficulty following through on instructionsFails to finish schoolwork or choresTrouble organizing tasks and activitiesLose items needed for tasks or activitiesEasily distractedForgets to do daily routine activitiesCommon Symptoms of Dyslexia (Please check all that apply)Started talking late as a childSlow to learning new wordsProblems forming words correctlyReversing sounds in wordsConfusing words that sound alikeReading below the expected level for ageStruggles remember names, letters, numbers, and colorsDifficulty learning nursery rhymes or playing rhyming gamesDifficult remember what you readProblems processing and understanding what is heardDifficulty finding the right word or forming answers to questionsCommon Symptoms of Auditory Processing Disorder (Please check all that apply)Difficult telling where sound is coming fromDifficult understanding words that are spoken quicklyDifficult understanding a person in a noisy roomStruggles paying attention when there is background noiseDifficulties with Reading and spellingStruggles following directions unless they are short and simpleDifficulty learning a new languageStruggles with singing or remembering lyrics to songsUnderstanding and remembering spoken informationTake longer to reply to someone who is talking to youOften need others to repeat themselvesDoes not understand sarcasm or jokesCommon Symptoms of Depression:Frequent Feelings of sadnessFrequent tearfulnessFrequent Feelings of emptinessFrequent Feelings of hopelessnessAngry outburstsFrequent Feelings of irritabilityConstant feelings of frustration, even over small mattersLoss of interest or pleasure in most or all normal activities, such as sex, hobbies, or sportsSleep disturbances, including insomnia or sleeping too muchTiredness and lack of energy, so even small tasks take extra effortReduced appetite and weight lossIncreased cravings for food and weight gainFeelings of anxiety, agitation, or restlessnessSlowed thinking, speaking or body movementsFeelings of worthlessness or guilt, fixating on past failures or self-blameTrouble thinking, concentrating, making decisions, and remembering thingsFrequent or recurrent thoughts of deathSuicidal thoughtsSuicide Planning or attemptsUnexplained physical problems, such as back pain or headachesCommon Symptoms of Anxiety (Please check all that apply)Feeling nervousFeeling restlessFeeling tenseHaving a sense of impending danger, panic, or doomHaving an increased heart rateBreathing rapidly (hyperventilation)TremblingFeeling weak or tiredTrouble concentrating or thinking about anything other than the present worryHaving trouble sleepingExperiencing gastrointestinal (GI) problemsHaving difficulty controlling worryHaving the urge to avoid things that trigger anxietyPersistent worryingOverthinking plans and solutions to all possible worst-case outcomesPerceiving situations and events as threatening, even when they are notDifficulty handling uncertaintyIndecisiveness and fear of making the wrong decisionInability to set aside or let go of a worryInability to relax, feeling restless, and feeling keyed up or on edgeCommon Symptoms of Oppositional Defiant Disorder (Please check all that apply)Angry and irritable moodOften and easily loses temperIs frequently touchy and easily annoyed by othersIs often angry and resentfulArgumentative and defiant behaviorOften argues with adults or people in authorityOften actively defies or refuses to follow adults' requests or rulesOften annoys or upsets people on purposeOften blames others for their own mistakes or misbehaviorHurtful and revengeful behaviorSays mean and hateful things when upsetTries to hurt the feelings of others and seeks revenge, also called being vindictiveCommon Symptoms of Pathological Demand Avoidance (Please check all that apply)Resisting and avoiding ordinary demandsUsing social strategies to avoid demandsObsessive behavior, often focused on other peopleBeing superficially sociable but lacking depth in understandingVery ImpulsiveExcessive mood swingsAverage Hours Per Day Playing Video Games Selected Value: 0 Average Hours Per Day Watching YouTube Selected Value: 0 Average Hours Per Day On Social Media Selected Value: 0 Average Hours Per Day On Computer for School/Work Related Selected Value: 0 Other Related Brain or Health Diagnoses and Symptoms *Please list and describe any other diagnoses or symptoms not listed abovePlease List Any Current Medications or Supplements: Rescheduling and Cancellation Policy *I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Rescheduling and Cancellation policy belowWe ask that you please reschedule or cancel at least 1 week before the beginning of your appointment. When you schedule an appointment we reserve all day especially for you. We respectfully request at least 5 business days if you are not able to come to your appointment. Individuals who cancel with less than 5 business days will be billed 50% your scheduled appointment. Individuals who cancel with less than 24 hour notice will be billed 100% of your scheduled appointment. Exceptions: Physical illness or travel restrictions due to sever weather. A Dr Note is required with name and date of service. Please understand that when you cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment. Clients on our waiting list are unable to adjust their schedule and travel plans. Thank you for respecting our time and ability to help others.Medical Waiver Agreement *I acknowledge that I have read, understood, and agree to the terms and conditions outlined in the Medical Waiver Agreement belowMedical Waiver Agreement: Client and or Client’s Guardian here in after referred to as “Client” understand and agrees to the following: 1. I acknowledge that Rocky Mountain Brain Integration is not a medical provider and does not offer medical diagnoses, treatments, or prescriptions. 2. I understand that any information provided by Rocky Mountain Brain integration is not a substitute for professional medical advice, diagnosis, or treatment. 3. I affirm that I have consulted with my healthcare provider regarding my medical conditions, and I will continue to do so during my association with Rocky Mountain Brain Integration. 4. I understand that Rocky Mountain Brain Integration may collect and handle my protected health information (PHI) in accordance with Health Insurance Portability and Accountability Act (HIPAA) 5. I authorize the disclosure of my PHI to Rocky Mountain Brain Integration for the purpose of providing non-medical support. 6. I release Rocky Mountain Brain Integration, its employees, and affiliates from any liability for injury, loss, or damage that may result from my participation in Rocky Mountain Brain Integration’s services. 7. I understand the risk associated with any activities or recommendations provided by Rocky Mountain Brain Integration and voluntarily assume these risks. I agree to: *I agree the above information is correct to the best of my knowledgeI agree to pay in full for all services rendered on the day of servicesPlease check ALL boxesDate *Signature (Parent's Signature for Clients Under 18 Years Old) *EmailSubmit
