Parent Survey





Yes, I would like to schedule a free consultation.

I would to schedule the consultation in the:

Your Name (required)

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What is your child's name?

What is your child's age?

Attention Stamina

Does your child's attention seem to be scattered?

Does your child have difficulty directing his/her attention?

Does your child have difficulty sustaining attention to a single task?

Visual Tracking

Does your child pay attention only when you or the teacher are in proximity (standing over child)?

Does your child lose attention immediately once you/teacher have moved out of proximity?

Does you child have difficulty participating in a sport and sustaining attention to his/her required task?

Does your child lose interest unless what he/she is viewing is highly visually stimulating?

Time On Task

Does your child have difficulty completing tasks by himself?

Does your child often fail to pay close attention to details or make careless mistakes in schoolwork or other activities?

Does your child frequently have difficulty sustaining attention during tasks or play activities?

Does your child avoid or become resistant to engage in tasks that require sustained mental effort like homework or seatwork at school?

When your child is working on an assignment independently, does he/she need constant redirection?

Short Term Memory

Does your child have difficulty following multiple commands?

Do you have to frequently repeat instructions for your child?

Does your child have difficulty memorizing math facts or spelling word?

Discriminatory Processing

Is you child often easily distracted by extraneous stimuli?

When trying to focus on a task, is your child easily distracted by background noises?

When trying to focus on a task, is your child easily distracted by visual distractions such as movement?

Spatial Memory

Does your child constantly lose things?

Does your child have difficulty organizing materials for school?

Does homework often disappear before it gets to the teacher?

Working Memory

Does your child often lose his train of thought?

Does your child have difficulty solving mathematical calculations in his/her head?

Does your child have difficulty reasoning or evaluating situations?

Social Skills

Does your child have difficulty making friends?

Does your child have difficulty adjusting his/her behavior in a group setting?

Does your child have difficulty making eye contact?

Does your child often interrupt conversations?

Does your child have difficulty taking turns?

Does your child often have conflicts with peers or siblings?

Motor Skills

Does your child seem to break things often?

Does your child have poor handwriting?

Does your child seem to have more accidents, bruises and scrapes than his/her peers?

Organization

Does your child frequently lose things?

Does your child have difficulty organizing tasks and activities?

Does your child require assistance from someone else to complete a project?

Does your child have difficulty managing time?

Behavior

Does your child exhibit behaviors that impede classroom performance?

Is you child less mature than you'd expect of his/her chronological age?

Does your child frequently fidget with hands or feet or squirms in seat?

Does your child often leave his/her seat in classroom or in other situation in which remaining seated is expected?

Does your child often run about or climb excessively in situations in which it is inappropriate? (In adolescents or adults may be limited to subjective feelings of restlessness.)

Does your child often have difficulty playing or engaging in leisure activities quietly?

Does your child often appear to be "on the go" or often acts as if "driven by a motor?"

Does your child often talk excessively?

Does your child often blurt out answers before questions have been completed?

Does your child often intrude on others at school or at home?


In your opinion, what are the top 3 skills your child needs to improve?

Other notes or comments

Thank you for submitting this survey. One of our specialists will contact you shortly to confirm your appointment time.

We will also email you a copy of the completed survey.

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