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Children
Adults
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Get in touch
Name
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First Name
Last Name
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Email Address
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Message
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Thank you!
CONTACT INFO
419.506.1262
Jon@yourmovementmatters.com
Tucson, Arizona, USA
If you would like to receive lessons for yourself or your child, please click on the appropriate link and fill out the form.
INQUIRY FORMS
Child Inquiry Form
Child Inquiry Form
Parent Name
*
First Name
Last Name
Contact Phone
*
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
MM
DD
YYYY
Child's Diagnosis
*
Current Medications / Supplements Your Child Is Taking
*
Has your child had any serious injuries / operations?
*
If so please explain.
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
Prop sit
Come to sit
Army crawl
Crawl on hands and knees
Stand on knees
Come to standing
Cruise along couch or furniture
Stand independently
Self-feed
Walk
Talk
Other
If selected "other" above, please describe:
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?
*
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?
*
How would you describe your child’s nature?
*
quiet, inquisitive, restless, anxious, playful, etc.
Please describe mealtimes with your child.
*
nursing, bottle fed, tube-fed, self-feed, other
What is your child’s sleeping schedule?
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still napping, what time of day, how long
Please describe briefly your child’s daily routine.
*
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 Jon Martinez - Movement Matters?
*
Date of acknowledgement
*
MM
DD
YYYY
Statement of Policy Regarding Intervention Modalities / Agreement and Release of Liability
Dear Parent, As you know, my work with your child focuses on movement learning. During the course of providing lessons for your child, I may comment on or answer questions from you or your family members regarding other intervention modalities (such as braces, standers, prescription drugs, a variety of therapeutic modalities, etc.) that in my experience have proven helpful or obstructive to my particular method of movement learning. At times, these comments may appear to be in conflict with advice you are receiving from your child’s medical professionals. It is important to keep in mind that my suggestions come from a movement learning perspective, while their advice comes from a medical perspective. Every child is unique and only you, having all of your child’s medical and other information, can make the appropriate choices for your child and coordinate medical and other care in a way that advances your child’s best interests. I am not a medical provider and cannot and do not offer medical advice. Where my suggestions appear to be in conflict with the suggestions of your child’s medical providers, it is imperative that you consult with those medical providers and understand from them the consequences and risks of the totality of your child’s care. It is your responsibility to inform the practitioner of any pre-existing conditions, limitations, specific sensitivities, or anything that may be relevant to your child’s lesson. You must inform your practitioner if at any time during the lesson you feel your child may be experiencing discomfort or pain. You understand that Jon Martinez/Movement Matters does not diagnose illness, disease, or any other disorder, and is not a substitute for medical examinations or care. You understand and voluntarily accept any risks relating to your child’s lesson and have been allowed the opportunity to ask questions regarding the inherent risks associated with your child’s lesson. You hereby release and hold harmless Jon Martinez/Movement Matters from any and all liability for injury or harm, including without limitation, personal, bodily or mental injury, economic loss, or damage resulting from your child’s lesson. Your practitioner may determine that it is unsafe to proceed with or continue any lesson due to health-related concerns. I understand that this agreement and release of liability applies to this and any and all future lessons or dealings that I may have with Jon Martinez/Movement Matters. Sincerely, Jon Martinez, Certified ABM for Children Practitioner
I have read and understand the foregoing statement of policy and have executed and delivered this acknowledgment as of the date indicated below:
*
Thank you!
ADULT INQUIRY FORM
Adult Inquiry Form
Name
*
First Name
Last Name
Contact Phone
*
(###)
###
####
Contact Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Occupation
*
Referred to this office by
Operations / Injuries
*
Purpose of this appointment
*
major complaint
When did these symptoms appear?
*
MM
DD
YYYY
What makes it better or worse?
*
Is it getting progressively worse?
*
Yes
No
Constant
Comes & Goes
How is the condition interfering with your daily routine?
*
Please explain why you would like to explore ABM
*
How did you hear about Jon Martinez & Movement Matters?
*
AGREEMENT & RELEASE OF LIABILITY
It is your responsibility to inform the practitioner of any pre-existing conditions, limitations, specific sensitivities, or anything that may be relevant to your lesson. You must inform your practitioner if at any time during the lesson you feel discomfort or pain. You understand that Jon Martinez/Movement Matters does not diagnose illness, disease, or any other disorder and is NOT a substitute for medical examinations or care. You understand and voluntarily accept any risks relating to your lesson and have been allowed the opportunity to ask any questions you have relating to the inherent risks associated with your lesson. You hereby release and hold harmless Jon Martinez/Movement Matters from any and all liability of injury or harm, including without limitation, personal, bodily or mental injury, economic loss, or damage resulting from your lesson. You understand that there may be times when Jon Martinez/Movement Matters may determine that it would be unwise to proceed with or continue any lesson due to health-related concerns. I understand that this agreement and release of liability applies to this and all future lessons or dealings that I may have with Jon Martinez/Movement Matters. Thanks, Jon Martinez / Movement Matters Certified ABM Practitioner
I have read and understand the foregoing statement of policy and have executed and delivered this acknowledgment as of the date indicated below:
*
Date of Signature
*
MM
DD
YYYY
Thank you!
