Tell Us About Your Child

Answering these questions helps us understand your child’s unique needs so we can offer meaningful next steps.

If you experience technical issues submitting this form, please contact [email protected]

Tell Us About Your Child

Answering these questions helps us understand your child’s unique needs so we can offer meaningful next steps.

If you experience technical issues submitting this form, please contact [email protected]

SECTION 1:
Household & Contact Info

Parent's First Name *

Parent's Last Name *

Child's Full Name *

Date of birth *

Gender *

City and State *

Email *

Phone *

Marital status *

SECTION 2:

Your Top Concerns

What is the #1 health goal you hope to make progress on in the next 6–12 months? *

If you could ease or remove three challenges from your child’s daily life, what would they be? *

Why are you seeking a functional approach? What draws you to this model of care? *

SECTION 3:

Current Support Network

For checkboxes, please mark all that apply.

Others, please specify:

What medical providers does your child see and for what? *

SECTION 4:

Developmental History

In my opinion, my child’s disability is:

Which statement most accurately describes your child’s language development? *

Did your child ever lose gross motor skills such as walking, running, jumping or climbing? *

Did your child ever lose fine motor skills such as drawing or doing finger movements to children’s songs? *

Did your child ever experience a regression in social skills (e.g. eye contact, ability or desire to play with peers, respond attempts at interaction)? *

Does your child have developmental delays? How far behind do you think they are at this time? *

Does your child have a diagnosis? (If so, when, what is diagnosis and whom did you see) *

SECTION 5:

What You’ve Already Tried

Other providers or therapies you have tried:

SECTION 6:

Improvements You’re Hoping For

SECTION 7:

What Makes This Hard

SECTION 8:

Support You’re Still Missing

What do you want as a solution that you have not received yet? *

SECTION 9:

Virtual Care Preference

Are you open to virtual/remote care? *

SECTION 10:

Understanding Program

Our care begins with developmental program, this may include multiple providers and coaching visits, designed to build a strong foundation for your wellness journey.
Packages are valid for 16 weeks and must be paid in full before program begins.

Are you financially prepared to move forward with the program if approved? *

SECTION 11:

Is This Program Right for You?

This program IS for you if:

You follow through with your commitments
You are someone who is fully committed to taking control of their child's development and determined to improve your child's health
This is an absolute must for you NOW
You and your spouse/partner are on the same page with moving forward

This program is NOT for you if:

You are unwilling to make nutrition changes for your child
You do not believe change is possible
You are unable or unwilling to invest in your child’s development

Before moving forward, please confirm the following: *

I understand this program requires active parent involvement and follow-through.

I am open to making thoughtful changes, including nutrition and lifestyle adjustments, if appropriate for my child.

I believe improvement is possible, even if I don’t yet know what that looks like.

I am applying intentionally and understand this is a guided, educational program, not emergency or medical care.

I have discussed this with my partner or support system, or I am prepared to move forward independently.

SECTION 12:

Next Step: Comprehensive Development Call

If your application is approved, the next step is a 60–90 minute Comprehensive Intake Call with Amber.

This call is $500 and includes:

A detailed review of your child’s full history
Clarifying patterns in behavior, development, sleep, nutrition, and gut health
A customized roadmap outlining next steps
Time for questions so you feel supported and confident moving forward

This call is required before entering the full program, and payment is collected at the time of scheduling.

Are you ready to take the next step in your child’s health journey? *

SECTION 13:

Submit

Thank you for sharing your child’s story. We review every submission with care and will reach out soon with next steps.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Privacy Policy | Terms of Service

This information is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation. For my full Disclaimer, please go to https://healingrootspediatrics.com/privacy-disclaimers-termsandconditions

Tell Us About Your Child

Answering these questions helps us understand your child’s unique needs so we can offer meaningful next steps.

If you experience technical issues submitting this form, please contact [email protected]

Tell Us About Your Child

Answering these questions helps us understand your child’s unique needs so we can offer meaningful next steps.

If you experience technical issues submitting this form, please contact [email protected]

SECTION 1:Household & Contact Info

SECTION 2:

Your Top Concerns

SECTION 3:

Current Support Network

SECTION 4:

Developmental History

SECTION 5:

What You’ve Already Tried

SECTION 6:

Improvements You’re Hoping For

SECTION 7:

What Makes This Hard

SECTION 8:

Support You’re Still Missing

SECTION 9:

Virtual Care Preference

SECTION 10:

Understanding Program

SECTION 11:

Is This Program Right for You?

SECTION 12:

Next Step: Comprehensive Development Call

SECTION 13:

Submit

SECTION 1:
Household & Contact Info