Neurofeedback/ craniosacral therapy

Prenatal, birth events, and/or injuries such as maternal stress, accident, drug exposure, difficult labor, forceps
delivery, breech birth, induced labor, anesthesia, anoxia, premature/late delivery, or post birth problems?
Other? Please describe.

Problems with growth and development, such as severe or recurrent illness or infections, allergies, emotional
difficulties, behavioral problems, appetite/digestion, language/speech, coordination? Walking or talking early?
Walking or talking late? History of ear infections? Please describe.

Physical trauma, injury, head injury, concussion, traumatic brain injury, accidents, high fever, serious illness,
surgery, CNS infection, poisoning, anoxia, stroke, heart attack? Ever broken your nose? Have you ever been to
the emergency room? Please describe.

Physical trauma, injury, head injury, concussion, traumatic brain injury, accidents, high fever, serious illness,
surgery, CNS infection, poisoning, anoxia, stroke, heart attack? Ever broken your nose? Have you ever been to
the emergency room? Please describe.

Psychological stresses/life changes during childhood, such as a death, parents’ divorce, losses, moves, or school
changes - or in adulthood, such as, job change or loss, loss of loved one, illness, or financial stress? Did you
experience emotional or physical abuse or neglect? Did you witness acts of violence? Please describe.

Any surgeries, hospitalizations, or medical treatments? Was general anesthesia used? Please describe.

Are you currently or recently on any medications, either prescription or OTC? If so, what is the indication for use? Have you ever used recreational drugs? If so, which drugs and how did each affect you?

Have you participated in any psychological therapies (with a psychologist, social worker, counselor, family therapist)? Have you ever been given a psychiatric diagnosis?

Family History. Have any close relatives experienced problems such as epilepsy, autism, Asperger's, alcoholism, mental illness, depression, suicide, incarceration, or any other problems Reviewed in this assessment? Please
describe.

What are your Goals?