Program Match Tool | Mindful Child Wellness

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Mindful Child Program Match Tool

Step 1 of 12

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How old is your child?
How old is your child?
- 0-2
- 3-4
- 5-7
- 8-12
- 13-17

Are you interested in aerial yoga classes or occupational therapy for your child?
Are you interested in aerial yoga classes or occupational therapy for your child?
- Aerial yoga classes
- Occupational therapy
- Both

What’s your child’s experience level with aerial yoga?
What’s your child’s experience level with aerial yoga?
- Complete beginner
- Done it once or twice
- Done it a few times
- Pretty much an expert

Has your child ever received occupational therapy?
Has your child ever received occupational therapy?
- Yes
- No
- I'm not sure

Does your child have any occupational challenges?
Select all that apply.
Does your child have any occupational challenges? Select all that apply.
- Learning or cognitive challenges
- Social and emotional challenges
- Behavioral challenges
- Motor function and physical challenges
- Other

What occupational challenges does your child face?
Select all that apply.
What occupational challenges does your child face? Select all that apply.
- Learning or cognitive challenges
- Social and emotional challenges
- Behavioral challenges
- Motor function and physical challenges
- Other

Please Describe What Other occupational challenges your child faces.
Please Describe What Other occupational challenges your child faces.

What are some therapy goals for your child we can help you accomplish?
Select all that apply.
What are some therapy goals for your child we can help you accomplish? Select all that apply.
- Sensory regulation
- Motor function
- Social skills
- Emotional regulation
- Focus & concentration

Which areas of growth apply to what your child needs most?
Select all that apply.
Which areas of growth apply to what your child needs most? Select all that apply
- Sensory regulation
- Motor function
- Social skills
- Emotional regulation
- Focus & concentration
- Not sure

Does your child have any physical limitations we should be aware of?
Does your child have any physical limitations we should be aware of?
- Yes
- No

Please elaborate on your child’s physical limitations so we can best help them.
Please elaborate on your child’s physical limitations so we can best help them.

Let us know how to get in touch with you, and we’ll match your child with one of our programs!
Parent/Guardian name(Required)
Child’s name(Required)
Phone(Required)
Email(Required)
Name
This field is for validation purposes and should be left unchanged.

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