Developmental Blueprint Application Form

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First Name *

Last Name *

Email *

Phone *

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By checking this box, I consent to receive marketing and promotional messages from Healing Roots Pediatrics, including special offers, program updates, and educational content. Message frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Privacy, Disclaimers, Terms & Conditions

Child's Full Name *

Child's Nickname *

Child's Date of Birth *

Marital status *

City and State *

Zip Code *

What is the #1 health goal you hope to make progress on in the next 6–12 months? *

If you could ease or remove three challenges from your child’s daily life, what would they be? *

Why are you seeking a functional approach? What draws you to this model of care? *

Other Therapies (please specify): *

What medical providers does your child see and for what? *

In my opinion, my child’s disability is: *

Which statement most accurately describes your child’s language development? *

Did your child ever lose gross motor skills such as walking, running, jumping or climbing? *

Did your child ever lose fine motor skills such as drawing or doing finger movements to children’s songs? *

Did your child ever experience a regression in social skills (e.g. eye contact, ability or desire to play with peers, respond attempts at interaction)? *

Does your child have developmental delays? How far behind do you think they are at this time? *

Does your child have a diagnosis? (If so, when, what is diagnosis and whom did you see) *

What do you want as a solution that you have not received yet? *

All care is provided virtually. This allows us to work with families across locations while maintaining a thoughtful, structured approach. Virtual visits are designed to support busy parents while still delivering high-quality care.

Are you open to receiving care virtually? *

Yes

No

I would like to learn more before deciding

Our process begins with a complimentary Discovery Call. If The Developmental Blueprint feels like the right fit for your family, we'll discuss the program structure, answer your questions, and review the investment before any decisions are made.

A quick note on insurance: We do not file with insurance, including Medicaid. If you move forward with care, fees are paid up front, which allows for longer visits and more personalized support than typical insurance-based care. You can use an HSA or FSA card, and we also offer third-party medical financing. Your insurance may still cover the majority of lab costs, so it is typically just our fees that are out of pocket, and these are often tax-deductible (save your receipts and consult your CPA).

Are you financially prepared to move forward with the program if approved? *

Yes, I’m ready.

I’m interested but need to talk through investment.

This program is likely A GOOD FIT if:
You are ready to take an active role in your child’s development
You are open to looking at nutrition, gut health, and foundational physiology
You understand that meaningful change takes time and consistency
You and your partner or support system are aligned in moving forward
This program may may NOT be the right fit if:
You are looking for a quick fix or immediate results
You are unwilling to make supportive changes at home
You prefer a symptom-only approach without exploring root contributors
You are seeking emergency or acute medical care

Before moving forward, please confirm the following: *

I understand this program requires active parent involvement and follow-through.

I am open to thoughtful changes, including nutrition and lifestyle adjustments when appropriate.

I understand that progress is a process, not an overnight solution.

I recognize this is a structured educational and development-focused program. It is not emergency or primary medical care.

I have discussed this decision with my partner or support system, or I am prepared to move forward independently.

The first step is a complimentary 15-minute Discovery Call with Amber.
The information you share in this form helps Amber review your child's situation before the call so your time together can be focused and meaningful.
This call gives us a chance to briefly understand your child's needs, answer initial questions, and determine whether The Developmental Blueprint may be the right fit for your family.
Before scheduling your Discovery Call, please note both parents/caregivers are required to attend this call. We’ll be discussing important decisions, and this conversation sets the foundation for your child’s success in the program.
If care with us feels aligned at the end of the Discovery Call, we will discuss the next steps and whether enrollment into The Developmental Blueprint makes sense for your family.

Are you open to starting with a complimentary call to explore next steps? *

Yes, I'm ready to get started.

Maybe. I have questions or need more time.

No, this isn’t the right time.

This information is for educational and informational purposes only and solely as a self-help tool for your own use. I am not providing medical, psychological, or nutrition therapy advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. Always seek the advice of your own medical practitioner and/or mental health provider about your specific health situation. For my full Disclaimer, please go to https://healingrootspediatrics.com/privacy-disclaimers-termsandconditions