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Success Story Form - After Using The Listening Program®

After you've finished with your initial use of the Listening Program® (TLP), we would love to hear your feedback on how the program has worked for you or your child. Please fill out the form below and submit it. Thank you in advance for the feedback!

 

Please note that all fields are required so we will have the information we need to assist you

First and Last Name:
(person completing story)

Relationship to person who completed TLP: (self, parent, teacher, etc)
Email
 Confirm Email:
 
First and Last Name:
(person who completed TLP)
 * Birth Date:
 (mm/dd/yyyy)
 / /
 
Gender
male female 		Age:
Your story about using the Listening Program:
 
 
 
Please read each of the following statements and rate improvement for each as follows:

  (0) Does not occur or apply due to age or circumstance
(1) shows no improvement
(2) shows little improvement
(3) shows moderate sometimes
(4) shows substantial improvement
(5) shows improvement so great it's no longer an issue

1. Ability to pay attention
0 1 2 3 4 5
2. Short-term memory
0 1 2 3 4 5
3. Reading comprehension
0 1 2 3 4 5
4. Spelling
0 1 2 3 4 5
5. Academic/job performance
0 1 2 3 4 5
6. Ability to start and/or complete projects
0 1 2 3 4 5
7. Distracted by background noise
0 1 2 3 4 5
8. Oversensitive to certain sounds
0 1 2 3 4 5
9. Understanding directions or instructions
0 1 2 3 4 5
10. Understanding similar sounding words
0 1 2 3 4 5
11. Understanding jokes/puns/humor
0 1 2 3 4 5
12. Asking "huh" or "what" ?
0 1 2 3 4 5
13. Discriminating sounds
0 1 2 3 4 5
14. Voice quality
0 1 2 3 4 5
15. Speech fluency and rhythm
0 1 2 3 4 5
16. Ability to sound out words
0 1 2 3 4 5
17. Word pronounciation
0 1 2 3 4 5
18. Ability to summarize a story/express thoughts
0 1 2 3 4 5
19. Hyperactivity
0 1 2 3 4 5
20. Posture (including slouching or slumping)
0 1 2 3 4 5
21. Coordination problems
0 1 2 3 4 5
22. Ability to organize and plan
0 1 2 3 4 5
23. Overwhelmed by 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. Tactfulness
0 1 2 3 4 5
26. Social skills
0 1 2 3 4 5
27. Burdened with everyday tasks
0 1 2 3 4 5
28. Stress/frustration tolerance
0 1 2 3 4 5
29. Understanding non-verbal communication
0 1 2 3 4 5
30. Self-image or self-confidence
0 1 2 3 4 5
  Please hit the submit button below to send your information.

 




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This site does not provide medical advice, diagnosis, or treatment and is intended for informational purposes only. No therapeutic relationship is established by the use of this site. Randi Fredricks is a Licensed Marriage Family Therapist MFC 47803. Randi Fredricks is not licensed with the California Medical Board or the Bureau of Naturopathic Medicine.
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