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Thumb Sucking Program Intake
First name
*
Last name
*
Email
*
Phone
*
About your child
How old is your child?
*
When does thumb sucking typically happen?
*
When falling asleep
When anxious, stressed, or upset
While watching TV or in quiet moments
Constantly throughout the day
Other (please describe below)
Readiness & motivation
Has your child expressed any interest in stopping, even casually?
*
Yes — they've brought it up themselves
Sort of — they're open to it when we talk about it
Not yet — this is mostly our concern right now
They've tried to stop before but struggled
In your own words, how does your child feel about the idea of stopping?
*
Has anyone else encouraged your child to stop — dentist, teacher, family members?
*
Background & goals
Is there anything else you'd like the team to know before your first visit?
Submit
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