Our Forms

1. Download the form(s) | 2. Print & Fill in | 3. Make an Appointment

Tomatis Form

01. Initial Tomatis Questionnaire

New Client Form

02. New Client Form (v2)

Adult Intake

03. Adult Intake Form

Cellfield Adult

04. Cellfield Adult Intake Form

Cellfield Child

05. Cellfield Child Intake Form

Listening SQ

00. Listening SQ

Your Symptoms. Check all that apply

Explosive rage/anger, lashing out

Aggressive, hostile, overly assertive

Agitated, upset, disturbed

Hyper focused, "locked in" on one thing

Nauseous, queasy or upset stomach

Difficulty taking decisions

Spacey, foggy, not "tuned in"

Hyperactive, excessive movement

Inactive, daydreaming, distracted

Impulsive, act without thinking

Feelings easily hurt, overly sensitive

Depressed, hopeless, sad

Cries easily, weepy, prone to tears

Low self-esteem, lacking self-confidence

Unable to plan, organize, or manage time

Difficulties with math

Teeth grinding, jaw clenching, TMJ

Tic (eye, mouth, other) spasms

Migraine headaches

Physical tension in body, taut, tense

Pressure in chest, discomfort in chest

Unpleasant physical sensations, pain

Tension headaches

Crawling sensation on skin, leg twitches

Difficulty grasping new information

Forgetful, difficulty remembering

Difficulty falling asleep

Disturbed sleep, wake often

Gasping for breath

Other (Please explain below)

15 + 5 =

If you are not sure, simply contact us below and someone will get in touch with you shortly.

Contact Dr. Adelina Coresi

Ask a question. For emergencies call 911 or visit your nearest hospital

12 + 7 =

(587) 390-3184

909 - 17th Ave SW, Suite 400, Calgary, AB, T2T 0A4, Canada

centre@brainwellnesscentre.com

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