Yes, I would like to schedule a free consultation.

I would to schedule the consultation in the:
Morning Afternoon Evening 

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?
Yes No N/A 

Does your child have difficulty directing his/her attention?
Yes No N/A 

Does your child have difficulty sustaining attention to a single task?
Yes No N/A 

Visual Tracking

Does your child pay attention only when you or the teacher are in proximity (standing over child)?
Yes No  N/A 

Does your child lose attention immediately once you/teacher have moved out of proximity?
Yes No  N/A 

Does you child have difficulty participating in a sport and sustaining attention to his/her required task?
Yes No N/A 

Does your child lose interest unless what he/she is viewing is highly visually stimulating?
Yes No N/A 

Time On Task

Does your child have difficulty completing tasks by himself?
Yes No N/A 

Does your child often fail to pay close attention to details or make careless mistakes in schoolwork or other activities?
Yes No N/A 

Does your child frequently have difficulty sustaining attention during tasks or play activities?
Yes No N/A 

Does your child avoid or become resistant to engage in tasks that require sustained mental effort like homework or seatwork at school?
Yes No N/A 

When your child is working on an assignment independently, does he/she need constant redirection?
Yes No N/A 

Short Term Memory

Does your child have difficulty following multiple commands?
Yes No N/A 

Do you have to frequently repeat instructions for your child?
Yes No N/A 

Does your child have difficulty memorizing math facts or spelling word?
Yes No N/A 

Discriminatory Processing

Is you child often easily distracted by extraneous stimuli?
Yes No N/A 

When trying to focus on a task, is your child easily distracted by background noises?
Yes No N/A 

When trying to focus on a task, is your child easily distracted by visual distractions such as movement?
Yes No N/A 

Spatial Memory

Does your child constantly lose things?
Yes No N/A 

Does your child have difficulty organizing materials for school?
Yes No N/A 

Does homework often disappear before it gets to the teacher?
Yes No N/A 

Working Memory

Does your child often lose his train of thought?
Yes No N/A 

Does your child have difficulty solving mathematical calculations in his/her head?
Yes No N/A 

Does your child have difficulty reasoning or evaluating situations?
Yes No N/A 

Social Skills

Does your child have difficulty making friends?
Yes No N/A 

Does your child have difficulty adjusting his/her behavior in a group setting?
Yes No N/A 

Does your child have difficulty making eye contact?
Yes No N/A 

Does your child often interrupt conversations?
Yes No N/A 

Does your child have difficulty taking turns?
Yes No N/A 

Does your child often have conflicts with peers or siblings?
Yes No N/A 

Motor Skills

Does your child seem to break things often?
Yes No N/A 

Does your child have poor handwriting?
Yes No N/A 

Does your child seem to have more accidents, bruises and scrapes than his/her peers?
Yes No N/A 

Organization

Does your child frequently lose things?
Yes No N/A 

Does your child have difficulty organizing tasks and activities?
Yes No N/A 

Does your child require assistance from someone else to complete a project?
Yes No N/A 

Does your child have difficulty managing time?
Yes No N/A 

Behavior

Does your child exhibit behaviors that impede classroom performance?
Yes No N/A 

Is you child less mature than you'd expect of his/her chronological age?
Yes No N/A 

Does your child frequently fidget with hands or feet or squirms in seat?
Yes No N/A 

Does your child often leave his/her seat in classroom or in other situation in which remaining seated is expected?
Yes No N/A 

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.)
Yes No N/A 

Does your child often have difficulty playing or engaging in leisure activities quietly?
Yes No N/A 

Does your child often appear to be "on the go" or often acts as if "driven by a motor?"
Yes No N/A 

Does your child often talk excessively?
Yes No N/A 

Does your child often blurt out answers before questions have been completed?
Yes No N/A 

Does your child often intrude on others at school or at home?
Yes No N/A 

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.