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Autism Nutrition Africa | Pre-Consultation Form

Gentle Feeding & Nutrition Support for Autism Families

Thank you for booking a consultation with Autism Nutrition Africa.

This short form helps us collect a few basic details before your appointment. We will discuss your child’s feeding, nutrition, medical history and individual needs together during the consultation.

It should take approximately three minutes to complete.

SECTION 1: PARENT OR GUARDIAN DETAILS

Parent or guardian’s full name

Email address

WhatsApp number

Please include your country code, for example +254 or +266.

City and country

For example: Nairobi, Kenya; Maseru, Lesotho; or London, United Kingdom.

SECTION 2: ABOUT YOUR CHILD

Child’s first name

Child’s age

Has your child received an autism diagnosis?

Yes.

Currently being assessed.

Not diagnosed.

Prefer not to say.

SECTION 3: YOUR CONSULTATION

What would you like support with?

Select all that apply.

What are your main feeding or nutrition concerns, and what would you most like help with during the consultation?

A few sentences are enough. We will explore the details together during your consultation.

Is your child currently taking any medications or supplements?

Please list any medications or supplements your child currently takes. Include the dose if you know it. If your child does not take any, write “None.”

Upload recent laboratory results or relevant medical reports, if available.

Accepts .jpg, .jpeg, .png, .pdf files

Size limit: 10 MB

Only upload reports you already have and would like reviewed. Laboratory testing is not required before your consultation. You may also email relevant documents to joyce@autismnutrition.org before your appointment.

SECTION 4: PRIVACY AND CONSENT

Your information will be treated confidentially and used only to prepare for and provide your child’s nutrition consultation. If you have questions about your information, please contact joyce@autismnutrition.org.

Parent or guardian consent

I confirm that I am the child’s parent or legal guardian and consent to Autism Nutrition Africa collecting and using this information to prepare for and provide my child’s consultation.