Professional Survey





I would to schedule the consultation in the:

Your Name (required)

Your Email (required)

Phone (required)

Brief description of the services you currently offer:

Do you work with children, adults, or both?

Attention Stamina

Do your clients’ attention seem to be scattered?

Do your clients have difficulty directing their attention for periods longer than a couple of minutes?

Do your clients have difficulty sustaining attention to a single task?

Visual Tracking

Do your clients pay attention only when you, the parent, the boss, or the teacher are in proximity (standing over clients)?

Do your clients lose attention immediately once you/teacher/boss have moved out of proximity?

Do your clients have difficulty participating in a sport and sustaining attention to his/her required task?

Do your clients lose interest unless what they are viewing is highly visually stimulating?

Time On Task

Do your clients have difficulty completing tasks by themselves?

Do your clients often fail to pay close attention to details or make careless mistakes in schoolwork, office work, or other activities?

Do your clients frequently have difficulty sustaining attention during tasks or recreational activities?

Do your clients avoid or become resistant to engage in tasks that require sustained mental effort like homework, balancing your checkbook, or office work?

When your clients are working on an assignment independently, do they need constant redirection?

Short Term Memory

Do your clients have difficulty following multiple commands?

Do you have to frequently repeat instructions for your clients?

Do your clients have difficulty memorizing names, facts or dates?

Discriminatory Processing

Are your clients often easily distracted by extraneous stimuli?

When trying to focus on a task, are your clients easily distracted by background noises?

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

Spatial Memory

Do your clients constantly lose things?

Do your clients have difficulty organizing materials for school or work?

Do homework or work assignments often disappear before it gets to the teacher or workplace?

Working Memory

Do your clients often lose your train of thought?

Do your clients have difficulty solving mathematical calculations mentally?

Do your clients have difficulty reasoning or evaluating situations?

Social Skills

Do your clients frequently have conflicts with peers, siblings, or spouses?

Are your clients frequently bullied by their peers?

Do your clients frequently bully their peers?

Do your clients have difficulty making eye contact?

Do your clients often interrupt conversations?

Do your clients have difficulty taking turns?

Have attention difficulties affected your clients personal relationships in a negative way?

Motor Skills

Do your clients seem to break things often?

Do your clients have poor handwriting?

Do your clients seem to have more accidents, bruises and scrapes than their peers?

Organization

Do your clients frequently lose things?

Do your clients have difficulty organizing tasks and activities?

Do your clients require assistance from someone else to complete a project?

Do your clients have difficulty managing time?

Behavior

Do your clients exhibit behaviors that impede classroom or workplace performance?

Do your clients frequently fidget with their hands or feet or squirm in their seat?

Do your clients often leave their seat in situations in which remaining seated is expected?

Do your clients often move about excessively in situations in which it is inappropriate? (In adolescents or adults may be limited to subjective feelings of restlessness.)

Do your clients often have difficulty playing or engaging in leisure activities quietly?

Do your clients often appear to be "on the go" or often act as if "driven by a motor?"

Do your clients often talk excessively?

Do your clients often blurt out answers before questions have been completed?

Do your clients often intrude on others at work or at home?

Have your clients experienced job loss due to an attention problem?

Are your clients less mature than you'd expect of their chronological age?

In your opinion, what are the top 3 skills your clients need 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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