• Client History and Application Form

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  • Please read the information in the Gettting Started document below before completing the Application and History Form. Print pages 5-7 of the Getting Started document and bring the completed pages to your evaluation.  

    To print these pages, click the black box (with the arrow in it) in the upper right-hand corner.  The printer icon will then be visable in the document's upper right corner.

    IMPORTANT NOTE:

    Please gather any documentation from previous medical and educational testing before beginning the application process. This form will take approximately 30 to 60 minutes to complete and cannot be saved during the process.

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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  •  -  - Pick a Date
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  • Client Information

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  •  -
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  •  -
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  •  -
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  • Watching this two-hour DVD is required before scheduling an appointment.  We recommend that both parents view this DVD if client is a minor.

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  • Family Information

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  •  -  - Pick a Date
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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  •  -  - Pick a Date
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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Medical History (Birth to Present)

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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.

  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Visual Information

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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.

  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.

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  • Auditory Information

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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Dietary

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  • Please submit the completed 7-day food diary located in the Getting Started document when you come for your evaluation. It is located at the first of this form as an attachment.

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  •  
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  •  
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  • Developmental

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  • Please indicate the age in months and years when the following developmental steps were achieved as well as any comments about that stage of development:

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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Indicate if the client enjoys the following activities and the AMOUNT OF TIME SPENT on each activity daily:

    Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
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  • Language

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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.

  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Manual

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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  •  
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  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
  • Minified React error #152; visit https://reactjs.org/docs/error-decoder.html?invariant=152&args[]=_Widget for the full message or use the non-minified dev environment for full errors and additional helpful warnings.
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  • Academics

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  •  
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  • Behavior

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  •  
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  • Overall Goals and Plan

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  • The Nuero-Developmental Approach is not a "quick fix". It takes time and dedication to build new neural pathways in the brain. It is a gradual process; changes will occur, but over a period of several months. It always amazes us how quickly our clients forget the struggles they have been dealing with for so long. They begin working the program and positive changes begin to occur and they quickly adapt to the new circumstances and forget that, prior to their work on the INP (Individualized NeuroDevelopmental Program), their child would only eat peanut butter and jelly sandwiches, or couldn’t sit still for five minutes, or couldn’t read or write, or screamed anytime they were touched, or never made eye contact, etc.

    This part of the History Form and Application document is for our future use; to remind you, if needed, what your goals are and what you are hoping to accomplish with the Little Giant Steps program. Some of our clients become weary after working the program for one year and they begin to lose sight of their original goals and they don’t remember how far they/their child has come because they are too close to the situation and because we humans adapt so quickly to new circumstances. If this should happen to you, we will use the information below to encourage you, motivate you and inspire you to keep on keeping on!!!

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  • Please Run the Wizard
  • Little Giant Steps (LGS) is a Christian educational organization. LGS utilizes an eclectic approach to eliminating learning, motor and speech inefficiencies. The developmental and educational plans are individualized for each client. Activities recommended are not medical, therapeutic, or psychological prescriptions. Activities are offered for the client and families’ review, investigation and education. Application of activities is the responsibility of the client and/or family. LGS Nuero-Educational Specialists are educators and are not licensed to practice medicine. If medical or other licensed professional advice is needed, the family is urged to consult a licensed physician or other licensed professional. I acknowledge that I have read and completed this information to the best of my knowledge and ability, and that I understand that Little Giant Steps or those trained by or employed by LGS are not assuming responsibility or liability for the client, and that I, as parent, guardian or client, assume full responsibility.

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  • Clear
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  • Should be Empty: