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Client Form
Name of Parent
Name of Child
Phone
City
State
Email
(Required)
How did you hear about us?
Child's age:
Child’s current functional grade level in reading:
Child’s current functional grade level in math:
List any labels given:
Child currently sees these specialists/therapists:
Please Check All That Apply:
Has difficulty following instructions or multistep directions
Is easily overwhelmed, even with common tasks
Has poor organizational skills
Has difficulty staying on topic in conversations
Struggles to stay on task or sustain attention
Seems to know something one day but cannot remember it the next
Is obviously bright but struggling with academic skills
Has trouble learning to read with a phonics approach or has poor reading comprehension
Loses place when reading, dislikes reading and/or makes careless mistakes in schoolwork
Dislikes writing or has poor handwriting/pencil grip
Has difficulty speaking where others can understand
Wants to continually watch things that spin or dangle
Is extremely ticklish and/or overly sensitive to fabrics, tags and seams
Is overly sensitive to certain food tastes and textures
Is overly sensitive to sounds or seems to not listen when spoken to directly
Runs and climbs excessively when it is not appropriate
Constantly feels restless
Grips the pencil too tightly
Is adopted or is in foster care
Has a history of seizures
Is deaf, blind or non-verbal
Has had ear infections and/or ear tubes
Has a history of emotional or behavioral disorders
Broke the arm opposite of the one currently used as the dominant hand between the ages 2 and 7
Has a low IQ according to diagnostic testing
Has sustained a traumatic/closed head injury
Had birth trauma resulting in a lack of oxygen or exposed to drugs or alcohol during gestation
Has received vision therapy
Sudden unexplained regression in verbal expression or motor skills
Food sensitivities or allergies
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