Filling Out the Forms

The information you provide on these forms is important to our assessment.

There are Six key forms.

(Click on the form name below for the PDF document)

1 – Intake Information
The purpose of this form is to provide general information for your child’s file. Please be sure to sign and date the form. Adult Form

2 – Release of Information
The purpose of this form is to give us permission to exchange pertinent information with the school or other professionals to assist in treating your child. Please be sure to sign and date the form.

3 – Neurodevelopmental Delay Checklist
This is information only you, as a parent, can provide because it relates to the influences that can affect a child’s neurological development. Check the items that apply.

4 – Learning and Behavior Rating Scale
The purpose of this form is to provide information regarding you child’s learning and behavior. Rate behavior and learning using the provided scale. (This is subjective. Simply jot down your first inclination on the 0-4 scale).

5 – Listening Skills Questionnaire
This important assessment looks difficult, but only requires you to check boxes.

6 – Credit Card Payment Form
Fill out this form and either drop it off or fax it to your assessment location to reserve your scheduled assessment.

Please contact us if you have any questions.