Client Application and History Form

Client History and Application Form
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.
Date: *

Month Day Year
Type of Program *

Individual Evaluation Advanced Brain Training 1 Jump Start 1
Podcast or Convention Code:
Form Completed by: *
Client Information
Client's Name *

First Name Middle Name Last Name
Best Contact Number *

Area Code Phone Number
Best E-mail Address: *
Street Address: *
City: *
State: *
Zip Code: *
Client's Date of Birth: *
Client's Sex: *

Male Female
Client's Height *
Client's Weight *
Please indicate the client's current grade level in school or occupation if not in school: *
Client's Educational / Employment Status: (Please check all that apply): *

Public School Private School Home School University Model School College Vocational /Trade School Employed part-time Employed full-time
If client is married, please indicate spouse's name:
If married, indicate spouse's occupation:
If client is a minor, please list parents' names:
Father's Contact Number:

Area Code Phone Number
Father's Email Address:
Mother's Contact Number:

Area Code Phone Number
Mother's Email Address
Client lives with: *

Parent Guardian Step Parent Self Spouse
Have you watched the two-hour Little Giant Steps DVD on the Neurodevelopmental Approach? *

Yes No
Watching this two-hour DVD is required before scheduling an appointment. We recommend that both parents view this DVD if client is a minor.
How did you learn about Little Giant Steps? (please be specific) *
Family Information
Is client adopted? *

Yes No
If yes, indicate country adopted from:
If adopted, how long was the client in foster care or an orphanage?
If adopted, how long was the client with his/her biological parents?
Father's Date of Birth

Month Day Year
Father's Education / Degree:
Father's Occupation:
Mother's Date of Birth

Month Day Year
Mother's Education / Degree
Mother's Occupation
Secondary Address if applicable:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Please list any siblings, their age and indicate if they are a previous client:
Medical History (Birth to Present)
Client's birth weight:
Client's Apgar Scores if known:
Please indicate the length of pregnancy:
Was the client delivered via C-Section?

Yes No
Please describe any complications during pregnancy and/or delivery or any medications taken during pregnancy:
At what age were there first concerns about the client's development and why?
Client's IQ if known:
List any labels or classifications:
List any pertinent medical, neurological, visual, hearing, therapeutic, psychological or educational testing. Please include dates, examiner, diagnosis and any recommendations.
Has the client ever received a head injury? *

Yes No
If the client has received a head injury, please describe the injury and include age:
Has the client ever broken any limbs? *

Yes No
If yes, indicate which limb(s):

Right Arm Left Arm Right Leg Left Leg
Indicate the age the injury(ies) occurred:
Describe any concerns with any organs, please be specific:
Does the client have headaches? *

Yes No
If yes, indicate how often, location and severity:
Has the client had any surgeries? *

Yes No
If yes, please indicate the type of surgery and the age:
List any medical conditions which place limitations on physical activity:
Is the client currently seeing a specialist? Please check all that apply:

Neurologist Counselor Psychologist Psychiatrist Nutritionist Vision Therapist Tutor Chiropractor Orthopedist Physical Therapist Music Therapist Occupational Therapist Cardiologist
Indicate and describe any medical testing the client has done such as an MRI, CAT Scan, Thyroid or blood testing:
If the client has had any seizures indicate the age(s) of occurance, frequency, length and type of seizure activity.
If applicable, list the type and current dosage of seizure medications:
List any other medications the client is taking as well as the dosage and how long the client has been taking the medication:
Please indicate any dietary supplements and vitamins the client is taking:
List any allergies, the age the allergies first became apparent and if the allergy is food related, chemical or environmental:
Please indicate if the client has had strep throat and how many times it has occurred:
Please describe any other health concerns the client is experiencing:
Describe the client's activity level including sports and exercise. Include the frequency and duration of any physical activities as well as the types of activities:
Has the client ever taken a three mile hike?

Yes No
Has the client ever run a mile without stopping?

Yes No
Please indicate the client's sleep times (ex. 8:30 pm to 7:00 am):
Does the client sleep with his / her mouth open?

Yes No Unknown
Does the client snore?

Yes No Unknown
Visual Information
Please check any conditions below the client has been diagnosed with:

near sighted far sighted astigmatism amblyopia strabismus macular problems glaucoma cataracts nystagmus color blindness cortical blindness blindness Irlen syndrome
Has the client had a recent eye exam?

Yes No
Does the client see 20/20?

Yes No
Indicate prescription if the client wears contact lenses or glasses:
Please check areas of visual concerns in regards to writing:

letter reversals mirror writing writing on a line avoidance of copy work difficulty copying from a blackboard coloring within the lines
Check all areas of visual concerns in regards to reading:

frequent loss of place failure to recognize the same word in the next sentence complains of eyes hurting / headaches when reading sees words or letters doubled or blurred holds reading material very close struggles to stay with reading / study skills confuses similar looking words eyes get tired / rubs eyes struggles to read poor in spelling problems with visual attention
Has the client ever received vision therapy? *

Yes No
If yes, describe any details such as how long ago and how long the client received services:
Does the client have poor eye contact?

Yes No
Auditory Information
Please indicate any auditory testing done and diagnoses received. Include dates and summarize results. If possible, bring copies with you to the evaluation.
Does the client have a history of colds or sinus congestion? *

Yes No
If yes, please list age(s) for each problem:
Does the client have a history of ear infections? *

Yes No
If yes, indicate the ear(s) affected as well as the ages the ear infections occurred.
Has the client suffered any hearing loss? *

Yes No
If yes, indicate the age the hearing loss occurred, which ears are affected, decibel range and cause of the hearing loss.
Does the client experience tinnitus (perception of noise or ringing in the ears)? *

Yes No
If yes, indicate the age of onset, which ears are affected as well as any family history of tinnitus:
Is the client overly sensitive to sounds?

Yes No
If yes, please indicate the age of the client when this was first observed as well as the past and current severity of symptoms:
Does the client experience tonal processing issues or often misinterpret words spoken?

Yes No
If yes, please give examples:
Has the client received any Tomatis, AIT, AET, SHS, Listening Program, and / or Samonas auditory training?

Yes No
If yes, please indicate the forms of auditory training with the dates and results:
Does the client experience physical tics (involuntary movements)?

Yes No
If yes, please give examples:
Does the client experience fears or phobias?

Yes No
If yes, please give examples:
Does the client listen to music?

Yes No
If yes, how many hours each day does the client listen to music?
Types of music listened to on a daily basis:
Please check any areas of concern below:

difficulty following directions short attention span distractability forgetful
Dietary
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.
Was the client nursed?

Yes No
At what age was the client weaned?
At what age was solid food started?
Please list any type of nutritional testing (blood analysis, hair analysis, urine analysis...) the client has had done and summarized the results:
Not including drinks mixed with water or juices, how many ounces of water does the client drink each day? *
Please describe the client's current diet:

Please choose the best option below: *

Excessive

Daily

Weekly

Rarely

Never

Water

Fruit juices

Caffeine / energy / soft drinks

Sugar / candy / desserts

Pastry / cereals/ starches

White flour

Dairy products

Fruits / Juice Plus+

Vegetables (not starchy)

Meats / eggs/ protein shakes

Whole grains / breads

Artificial colorings

Artificial sweeteners

Tobacco

Alcohol

Please choose the best option below: *

No Concern

Mild Concern

Concerned

Moderate Concern

Very Concerned

Physical endurance

Coordination

Balance

Crawling

Walking

Running

Weak

Physical activity level

Ataxic

Runs into walls / people

Spills milk often

Muscle tone (low or high)

Fine motor

Left / right confusion

Bedwetting / incontinence

Sucks thumbs / fingers

Overly ticklish

Overly sensitive to tags / seams

Overly sensitive to sunlight

Overly sensitive to pain

Low tolerance of pain

High tolerance of pain

Overreacts to small scratches

Bites nails / fingers/toes

Falls out of chairs

Processing / timing rate

Does not feel hunger

Does not know when full

Does not respond when hurt

Does not respond to spankings

Bruises yet not able to say why

Overly rough when playing

Hugs too hard

Problems with hair cuts

Problems with brushing / washing hair

Unaware of outdoor temperature

Temperature of shower too hot

Tics

Please check any concerns in the following areas:

poor appetite picky eater overeating anorexia / bulimia gag reflex food cravings overly sensitive to food textures overly sensitive to tastes overly sensitive to odors does not notice smells picky about food temperatures notices smells more than other members of the family
Include any additional information for items previously checked that you want us to be aware of:
Name 2-3 foods the client does not like to eat:
Developmental
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:
Crawled on stomach:
Crept on hands and knees:
Walked:
Toilet trained:
First word (at what age):
Use of couplets (two words together) at age:
3-4 word phrases at age:
Spoke in sentences at age:
Conversational language
Initial word recognition / reading started at age:
Indicate if the client enjoys the following activities and the AMOUNT OF TIME SPENT on each activity daily:
Watching TV (time spent):
Computer / video games (time spent):
Looking at / reading books (time spent):
Being read to (time spent):
Language
Please describe any concerns about the client's language ability:
Put a check in the box if there are any concerns in the following areas:

stammering stuttering drools aphasia difficulty chewing mouth breathing
Indicated any concerns with the client's articulation (making specific sounds correctly). Please be specific:
Does the client use sign language:

Yes No
If yes, please indicate fluency rate:
Is the client able to say a sentence in another language:

Yes No
If yes, please indicate the language:
Manual
Check the box where there may be a concern:

tying shoes buttons / zippers/ snaps poor pencil grasp sloppy writing opening lids / jars/ cans / bags
Is the client able to type?

Yes No
If yes, does the client know the home row keys?

Yes No
How many words per minute can the client type?
Does the client print with both upper and lower case letters?

Yes No
Does the client write in cursive?

Yes No

Please indicate whether the client uses the right, left or both hands for each of the following: *

Right Hand

Left Hand

Both Hands

writing

eating

throwing

sports

drawing/coloring

brushing/combing hair

brushing teeth

Have you ever thought that this person should really be using the opposite hand? *

Yes No
Did it take long for the client to choose a dominant hand?

Yes No
Was the client encouraged to use one hand over another at an early age (before 7 years old)? *

Yes No
Does the client have an identical twin?

Yes No
If so, which hand does the twin use?
Are any of the following people (who are biologically related to the client) either left handed or considered to be ambidextrous? *

Mother Father Siblings Grandparents Aunts Uncles First Cousins Adopted/unknown No
Academics
Are there are concerns in these areas (check all that apply):

poor at testing reading comprehension math word problems logical thinking math computation math facts reading math concepts

Rate math fact mastery as good, average, poor or not introduced for the following operations:

Good

Average

Poor

Not yet Introduced

Addition

Subtraction

Multiplication

Division

Please list all schools/ programs attended (including dates, grades and degrees). If home schooled, please list curriculum used:
Please list any learning labels or classifications given to the client:
What, if any, extracurricular activities, sports or lessons does the client participate in:
Behavior

Please indicate the level of concern in each area below.

No Concern

Mild Concern

Concerned

Moderate Concern

Very Concerned

Hyperactive

Hypoactive (low activity level)

Impulsive

Explosive temper

Anger (non explosive)

Low frustration level

Temper tantrums

Destructive Behavior

Aggressive behavior

Cyclical Behavior (good days/bad days)

Academic output (good days / bad days)

Overly sensitive in general

Perseveration

Follow through

Avoidance behavior

Difficulty with parents

Difficulty with siblings

Difficulty with teachers

Difficulty with peers

Competitive

Socially immature

Few or no friends

Emotional Overreacts

Social

Compliant

Cooperative

Obedient

Perfectionist

Disorganized

Flexible

Rigid / Inflexible behavior

Poor judge of time

Desire to withdraw

Suicidal

High acheivement

Low acheivement

Does the client have any emotional or behavioral difficulties?

Yes No
If yes, please describe the concerns:
Is there a family history of emotional or behavioral disorders?

Yes No
If yes, please describe.
Please describe the client's specific positive and negative behaviors:
Overall Goals and Plan
Please list behavioral goals and expectations:
What are your academic goals and expectations?
Please indicate who will be working with the client and the amount of time each day (5 days a week) available:
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!!!
What is the main issue that brought you to Little Giant Steps?
What is the biggest behavioral issue you are dealing with that you would like to see changed? (for example: explosive temper, avoidance behavior, destructive, aggressive, lack of tolerance or patience, too competitive...). Please be specific and expound on any concerns in this area.
This program is not for the faint of heart, list one or more issues that you would like to see resolved for yourself/your child. You may say something such as: "If this one thing or these things would go away; all the time, effort and money invested on this program would be worth it!!"
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.
Signature *

Clear
Please attach a photo of the client:
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Client History and Application Form

Client Information

Family Information

Medical History (Birth to Present)

Visual Information

Auditory Information

Dietary

Developmental

Language

Manual

Academics

Behavior

Overall Goals and Plan