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

All care is provided virtually. This allows us to work with families across locations while maintaining a thoughtful, structured approach. Virtual visits are designed to support busy parents while still delivering high-quality care.

Are you open to receiving care virtually? *

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 likely A GOOD FIT if:

You are ready to take an active role in your child’s development
You are open to looking at nutrition, gut health, and foundational physiology
You understand that meaningful change takes time and consistency
You and your partner or support system are aligned in moving forward

This program may may NOT be the right fit if:

You are looking for a quick fix or immediate results
You are unwilling to make supportive changes at home
You prefer a symptom-only approach without exploring root contributors
You are seeking emergency or acute medical care

Before moving forward, please confirm the following: *

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

I am open to thoughtful changes, including nutrition and lifestyle adjustments when appropriate.

I understand that progress is a process, not an overnight solution.

I recognize this is a structured educational and development-focused program. It is not emergency or primary medical care.

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

SECTION 12:

Next Step: Getting Started

The first step is a complimentary 15-minute Zoom call with Amber. This gives us a chance to briefly understand your child’s needs, answer initial questions, and determine if this is the right fit for your family.

If it feels aligned, the next step is a 60–90 minute Comprehensive Development 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 step allows us to go deeper and determine the most appropriate level of care for your child.

Are you open to starting with a complimentary call to explore next steps? *

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

SECTION 10:

Understanding Program

SECTION 11:

Is This Program Right for You?

SECTION 12:

Next Step: Getting Started

SECTION 13:

Submit

SECTION 1:
Household & Contact Info