About You And The Person Being Assessed

Your Name

Date

Email address

The Child's Name

Age of the child

Who Lives In The Child's Primary Home?

Please briefly tell me who your child lives with and any regular caregiving arrangements that may be important for me to understand.

What Are You Noticing? What Led You To Seek Consultation At This Time?

Tell me what you have been noticing in your child's behavior, emotions, relationships, development, or daily functioning and what has you concerned.

Please Tell Me More About The Concerns You Selected

What does this look like in everyday life? When does it tend to happen, who is usually present, and what seems to make it better or harder?

When did you first begin noticing these concerns?

Have There Been Any Recent Changes In Your Child's Life Or Family?

What Would You Like Me To Know About Your Child's Strengths, Interests, Personality, And The Things They Enjoy?

Does Your Child Currently Attend Preschool, Daycare, Gan, School, Or Another Regular Childcare Setting?

If Yes, Please Briefly Describe The Setting And Anything The Teachers Or Caregivers Have Been Noticing

Has Your Child Previously Had Any Developmental, Psychological, Occupational Therapy, Speech, Educational, Or Other Evaluation?

Yes

If Yes, Please Briefly Tell Me What Was Evaluated And When

You do not need to upload records with this inquiry. I will let you know if particular records would be helpful if we proceed.

What Are You Hoping To Better Understand About Your Child?

What questions would you most like this consultation to help answer?

What Would Feel Different For Your Family If This Consultation Were Helpful?

Which Consultation Format Are You Interested In?

Virtual consultation

In-person consultation (available only in Israel)

I am not sure which is appropriate

Name Of Referring Professional

Anything else you think I should know?

BEFORE SUBMISSION

What Happens After You Submit

I personally review each Early Childhood Developmental & Attachment Consultation inquiry. I will consider your child's age, the concerns you have described, what you are hoping to better understand, where your family is located, and whether this consultation appears appropriate for your family's needs.

I may respond by email with a few additional questions or offer a brief call when I need clarification. If the consultation appears to be a good fit, I will explain the recommended consultation structure, complete fee, what information or records may be helpful, and the anticipated timeline.

You will have an opportunity to review that information before deciding whether you would like to proceed. If you choose to move forward, you will complete the service agreement and submit the 50% deposit before the consultation process begins.

Acknowledgment

Please confirm the following before submitting your inquiry: Required checkbox I understand that submitting this inquiry does not establish a therapist-client relationship, guarantee that NMT is appropriate for my situation, or commit me to beginning an assessment.

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