Thursday, November 20, 2008




















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The Listening Program® Screening Form

Our Listening Program® screening will help us to determine which Listening Program® is most appropriate for you. It is not intended to replace a consultation. Once we receive your information, we will contact you to set up an appointment for your free Listening Program®. In the meantime, please feel free to call us at 800-957-5655.

 

Please note that all fields are required so we will have the information we need to assist you
First and Last Name:
(person completing screening)

Relationship to person being screened:
(self, parent, teacher, etc)
Email
 Confirm Email:
 
First and Last Name:
(person being screened)
 * Birth Date:
 (mm/dd/yyyy)
 / /
 
Gender
male female 		Age:
Please tell us about the person that will be using the Listening Program: (limit to 250 characters with spaces)
 
 
 
Please read each of the following statements and rate each as follows:

  (0) Does not occur or apply due to age or circumstance
(1) If it never occurs
(2) If it occurs rarely
(3) If it occurs sometimes
(4) If it occurs often
(5) If it occurs always

1. Difficulty paying attention
0 1 2 3 4 5
2. Poor short-term memory
0 1 2 3 4 5
3. Poor reading comprehension
0 1 2 3 4 5
4. Difficulties spelling
0 1 2 3 4 5
5. Low academic/job performance
0 1 2 3 4 5
6. Difficulty starting and/or completing projects
0 1 2 3 4 5
7. Easily distracted in presence of background noise
0 1 2 3 4 5
8. Is oversensitive to certain sounds
0 1 2 3 4 5
9. Misunderstands directions or instructions
0 1 2 3 4 5
10. Confuses similar sounding words
0 1 2 3 4 5
11. Difficulty understanding jokes/puns/humor
0 1 2 3 4 5
12. Frequency asks “huh” or “what”
0 1 2 3 4 5
13. Difficulty discriminating sounds
0 1 2 3 4 5
14. Flat and monotonous voice quality
0 1 2 3 4 5
15. Speech lacks fluency and rhythm
0 1 2 3 4 5
16. Difficulty sounding out words
0 1 2 3 4 5
17. Mispronounces words
0 1 2 3 4 5
18. Difficulty summarizing a story/expressing thoughts
0 1 2 3 4 5
19. Hyperactivity
0 1 2 3 4 5
20. Has poor posture, including slouching or slumping
0 1 2 3 4 5
21. Has coordination problems
0 1 2 3 4 5
22. Difficulty with organization and planning
0 1 2 3 4 5
23. Is overwhelmed with sensory information
0 1 2 3 4 5
24. Confusion of right and left and/or location and direction
0 1 2 3 4 5
25. Lack of tactfulness
0 1 2 3 4 5
26. Poor social skills
0 1 2 3 4 5
27. Feels overburdened with everyday tasks
0 1 2 3 4 5
28. Low stress/frustration tolerance
0 1 2 3 4 5
29. Difficulty reading non-verbal communication
0 1 2 3 4 5
30. Poor self-image or low self-confidence
0 1 2 3 4 5
  Please hit the submit button below to send your information.

 




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