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INTAKE FORM

At Biomedical Healing for Kids, our mission is to empower children to thrive by addressing the root
causes of their health challenges with compassion, expertise, and evidence-based care. Led by
Greer McGuinness—a Registered Dietitian, certified Detox Specialist, Master Herbalist, and proud
autism mom—we offer a holistic approach to health and well-being that is as unique as your child.


This Patient Intake Form is your first step on the journey toward creating a personalized,
comprehensive plan to support your child’s healing. By understanding their health history, behaviors,
and challenges, we can develop tailored strategies to address their specific needs and guide your
family toward meaningful, lasting improvements.


We’ve designed this form to gather essential information that will help us craft a plan uniquely suited
to your child. Please complete it as thoroughly as possible, knowing that every detail brings us closer
to understanding how we can best support your child on their path to thriving.

Date of Birth
Gender
Preferred Method of Communication
Primary Concerns: What are your main concerns regarding your child’s health? (Check all that apply)

HEALTH HISTORY

Does your child have a formal diagnosis?

Birth and Early Development

Were developmental milestones met on time (e.g., crawling, walking, talking)?
Were there any complications during pregnancy or birth?
Any hospitalizations or surgeries?

Medical Conditions

Multi choice

Past and Current Medications or Treatments

Current Therapies

Diet and Nutrition

Describe your child’s current diet:
Does your child have any known food allergies or sensitivities?

Behavioral and Emotional Profile

Common Behaviors: (Check all that apply)

Emotional Challenges:

Does your child show signs of anxiety or depression?
Sensory Sensitivities:

Gut Health and Physical Symptoms

Digestive Symptoms:
Other Physical Symptoms:
Does your child have difficulty falling or staying asleep?
Does your child rely on supplements to fall asleep most nights?
Does your child wake up feeling rested?

Environmental and Toxin Exposure

Has your child been exposed to any of the following?
Does your home environment include any of the following?

Education and Social Interaction

School Setting:
Does your child receive any accommodations or therapies through school?

Goals and Expectations

Instructions
1. Complete this form thoroughly. It’s designed to gather essential information about your child’shealth.


2. Submit the form via our secure portal or email it to greer@biomedicalhealingforkids.com.


3. If you’ve booked an Introduction Call, this form will guide the discussion during yourappointment.

During the Initial Appointment
When you book your Introduction Call, we will:

Review Intake Forms: Greer will go over this form and any additional documentsyou submit.

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Discuss Current Concerns: Share your child’s symptoms, behaviors, andchallenges in an open, supportive discussion.

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Assess Foundational Health: Explore your child’s diet, sleep patterns, gut health,environmental exposures, and nutrient status.

 

Set Goals: Collaborate to establish realistic and meaningful health goals for yourchild. 

 

Next Steps: Greer will outline a clear plan, including dietary adjustments, lab tests,supplement regimens, and foundational therapies.

Important Next Steps

 

Thank you for providing this valuable information. If you’ve scheduled an Introduction Call, Greer McGuinness will review this form with you during your appointment and discuss personalized strategies to support your child’s health and well-being. 

 

We’re honored to partner with you on your child’s journey toward better health.

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