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1:1 Intake Forms

Fill out these forms before your 1:1 session

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Question 1 of 8

Is your call in regards to...

A

Formula Feeding

B

Combo-feeding

C

Breastfeeding Issues

D

Starting Solids

E

Other...

Question 2 of 8

How old is your baby?

Question 3 of 8

What would you like to accomplish during your session with Erin?

Question 4 of 8

What are your baby feeding goals?

Question 5 of 8

How is your baby currently being fed? If your baby is on formula, what do you use? Are you happy with it?

Question 6 of 8

What is your baby's feeding and sleep schedule?

Question 7 of 8

What is your instagram handle? (no need to provide, but it is handy if we have talked before)

Question 8 of 8

By submitting this assessment I agree and confirm that I understand that:

 

Erin Moore, RN, CPNP, CLC is a licensed provider, but is not your child’s provider. By providing information Ms. Moore is not providing any nursing or medical services. While Ms. Moore is a trained nurse practitioner, she is also a certified lactation counselor and is solely providing services to individuals under this certification as a coach. Ms. Moore strongly encourages all parents and guardians to contact their child’s pediatric provider for any medical needs related to the information she provides.  Ms. Moore does not promise, shall not be obligated to, and will not provide any nursing or medical service, diagnosis, or treatment to you or your child. If diagnosis, treatment, or medical services are required, Ms. Moore encourages you to seek services from an appropriately licensed professional.

 

 

At no time does advice provided by Ms. Moore supersede or replace advice provided by any medical or behavioral health professional that has a treating relationship with your child. 

 

A

Yes, I agree

Confirm and Submit