ABM Child Lesson Request Form

I work with children in what we call “intensives,” that is a cluster of 6 to 10 lessons given over a week. This usually means two lessons per day. A break, for the child, of at least 45 minutes between the lessons is needed.

The Anat Baniel Method wakes up the child’s brain to create new connections, often at a staggering rate, leading to spontaneous, often extraordinary breakthroughs in movement, thinking, self-regulation, and connection with others.

Please fill in the form below and I will promptly reply to your ABM for Child lesson request.

Child Inquiry Form

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

E-Mail Address*

City*

Country*

Child's Name:

Child's Date of Birth

Month

Day

Child's Diagnosis

What is your child currently able to do on his / her own?

	Track object with eyes
	Turn head to both sides
	Roll to each side
	Reach for toys
	Transfer objects
	Roll from back to belly
	Roll from belly to back
	Push up on Belly
	Babble or make sounds
	Sit
	Come to sit
	Army crawl
	Crawl on hands and knees
	Stand on knees
	Come to standing
	Cruise along furniture
	Stand independently
	Self-feed
	Walk
	Talk
	Other

If selected "other" above, please describe:

Has your child had any serious injuries / operations?

Current Medications / Supplements Your Child Is Taking

What therapies does your child receive at this time?
traditional or alternative

How often do they receive these therapies and what are the current goals?

Support devices:

Is your child using support devices in therapy, home, or school settings?

If so, please describe which ones and how often they are used?
(baby swings, jumping devices, special chairs, walkers, standers, AFO’s, braces, splints, wheelchair, etc.)

How much floor time does your child have each day?

What sort of activities does your child like and dislike?What sort of toys and activities does your child like and dislike?

How would you describe your child’s nature? * quiet, inquisitive, restless, anxious, playful, etc.

Is there anything else you would like to add to help me better understand your child?

What short term goals would you, as a parent, like to see your child accomplish in the upcoming months?

How did you hear about Anat Baniel Method / Neuroness?

GDPR*

	I am at least 16 years of age.
	I have read and accept the privacy policy.
	I understand that you will use my information to contact me or send me the information I requested.

Please enter the word that you see below.

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ABM Child Lesson Request Form

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