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.

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

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A holistic centre
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Contact Us

07849 302786

enquiries@naomisgarden.org

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

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