Adult Initial Consultation Form

Thank you for your interest in Naomi’s Garden Conductive Education. In order for us to have the best understanding of you and and how to meet your individual needs, please fill out this form with as much detail as possible. After you have returned the completed form to us, we will be in contact with you to arrange your initial consultation. Please note, your initial consultation will be free of charge and will be followed by a full Conductive Education report.

Full Name

Date of Birth

Address

Parent / Carer Names

Contact Number

Email Address

Full Diagnoses

In your own words, explain your story so far, including dates of diagnosis, previous and current therapies, surgeries, your personal aims and goals, likes and dislikes and another information you feel is important for us to get a better understanding of you.

Do you take any medication that you feel we need to know about? If so please list below.

Have you accessed Conductive Education before? Yes No

If you answered yes above, please provide more detail below

Below are some activities, tasks and skills that will be included in the task series at Naomi’s Garden. It is important for us to have an idea before we meet you how you problem solve these activities and for us to tailor our sessions to your needs. There are boxes numbered 1-5, 1 being that you need full support in the area and 5 being you can complete the task independently. If there are some areas that are not applicable to you, just mark them N/A. Please tick as accurately as possible, using the space provided at the end of each section to give us any further information you feel we should know.

	1 - Needs Much Help	2	3 - Needs Some Help	4	5 - Completes Independently	N/A
Eating
Getting Dressed
Toileting
Brushing Teeth
Washing Self

Self-Care Skills: Other Comments

Physical Tasks

	1 - Needs Much Help	2	3 - Needs Some Help	4	5 - Completes Independently	N/A
Rolling on to left side
Rolling on to right side
Rolling completely over
Lifting arms above head
Grasping and Letting go
Bending ankles up and down
Lifting hips up and down
Sitting up with crossed legs
Sitting up with diamond sitting
Sitting up with straight legs
Sitting in an unsupported chair
Holding head up while sitting
Reaching forward when sitting
Completing tasks/playing while sitting
Picking things up from the floor while in sitting
Standing up from floor
Standing up from chair
Standing independently
Crawling
Four Point Kneeling
High kneeling
Initiating stepping independently
Walking forwards
Walking Backwards
Crouching Down

Any other comments from the section of physical development. Please include any details of equipment you use on a daily basis.

Please add any comments relating to social and communication skills. Please also include any speech and communication aids that your child uses on a day to day basis.

Please detail 3 main areas that you feel are priority for us to work on with you. For example, 1 - To improve head control, 2 - To improve grasp and release 3 - To improve stepping and weight bearing

Lastly, please tell us where you heard about us

I consent to Naomi’s Garden storing and using the data above for making contact and for the purpose of fulfulling a contract. I understand this data will never be passed on to third-parties and I am aware that I can withdraw my consent at any time.

A holistic centre
for wholeness

07849 302786

enquiries@naomisgarden.org

Bowen House, Manby Park, Louth, Lincolnshire LN11 8UT

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Adult Initial Consultation Form

A holistic centre for wholeness

07849 302786

enquiries@naomisgarden.org

A holistic centre
for wholeness