Client Application and History Form

Client History and Application Form

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.
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.

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.
Date: *

Month Day Year
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.
Type of Program *

Individual Evaluation Advanced Brain Training 1 Jump Start 1

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.
Podcast or Convention Code:
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.
Form Completed by: *
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.
Client Information

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.
Client's Name *

First Name Middle Name Last Name
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.
Best Contact Number *

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

Male Female
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.
Client's Height *
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.
Client's Weight *
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.
Please indicate the client's current grade level in school or occupation if not in school: *
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.
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

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.
If client is married, please indicate spouse's name:
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.
If married, indicate spouse's occupation:
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.
If client is a minor, please list parents' names:
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.
Father's Contact Number:

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

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

Parent Guardian Step Parent Self Spouse

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.
Have you watched the two-hour Little Giant Steps DVD on the Neurodevelopmental Approach? *

Yes No
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.
Watching this two-hour DVD is required before scheduling an appointment. We recommend that both parents view this DVD if client is a minor.

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.
How did you learn about Little Giant Steps? (please be specific) *
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.
Family Information

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.
Is client adopted? *

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

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

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

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

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.
Please list any siblings, their age and indicate if they are a previous client:
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)

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.
Client's birth weight:
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.
Client's Apgar Scores if known:
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.
Please indicate the length of pregnancy:
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.
Was the client delivered via C-Section?

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

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

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

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

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

Yes No
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.
If yes, please indicate the type of surgery and the age:
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.
List any medical conditions which place limitations on physical activity:
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.
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

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 and describe any medical testing the client has done such as an MRI, CAT Scan, Thyroid or blood testing:
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.
If the client has had any seizures indicate the age(s) of occurance, frequency, length and type of seizure activity.
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.
If applicable, list the type and current dosage of seizure medications:
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.
List any other medications the client is taking as well as the dosage and how long the client has been taking the medication:
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.
Please indicate any dietary supplements and vitamins the client is taking:
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.
List any allergies, the age the allergies first became apparent and if the allergy is food related, chemical or environmental:
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.
Please indicate if the client has had strep throat and how many times it has occurred:
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.
Please describe any other health concerns the client is experiencing:
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.
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:
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.
Has the client ever taken a three mile hike?

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

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

Yes No Unknown
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.
Does the client snore?

Yes No Unknown
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

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.
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

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.
Has the client had a recent eye exam?

Yes No

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.
Does the client see 20/20?

Yes No
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 prescription if the client wears contact lenses or glasses:
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.
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

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.
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

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.
Has the client ever received vision therapy? *

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

Yes No
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.
Auditory Information

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.
Please indicate any auditory testing done and diagnoses received. Include dates and summarize results. If possible, bring copies with you to the evaluation.
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.
Does the client have a history of colds or sinus congestion? *

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

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

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

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

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

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

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

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

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

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

difficulty following directions short attention span distractability forgetful
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

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.
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.

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.
Was the client nursed?

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

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
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.
Include any additional information for items previously checked that you want us to be aware of:
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.
Name 2-3 foods the client does not like to eat:
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.
Developmental

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.
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:

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.
Crawled on stomach:
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.
Crept on hands and knees:
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.
Walked:
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.
Toilet trained:
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.
First word (at what age):
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.
Use of couplets (two words together) at age:
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.
3-4 word phrases at age:
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.
Spoke in sentences at age:
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.
Conversational language
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.
Initial word recognition / reading started at age:
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.
Watching TV (time spent):
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.
Computer / video games (time spent):
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.
Looking at / reading books (time spent):
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.
Being read to (time spent):
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.
Language

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.
Please describe any concerns about the client's language ability:
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.
Put a check in the box if there are any concerns in the following areas:

stammering stuttering drools aphasia difficulty chewing mouth breathing

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.
Indicated any concerns with the client's articulation (making specific sounds correctly). Please be specific:
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.
Does the client use sign language:

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

Yes No
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.
If yes, please indicate the language:
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

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.
Check the box where there may be a concern:

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

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

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

Yes No
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.
Does the client write in cursive?

Yes No
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.

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
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.
Did it take long for the client to choose a dominant hand?

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

Yes No
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.
Does the client have an identical twin?

Yes No
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.
If so, which hand does the twin use?
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.
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
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.
Academics

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.
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
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.

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:
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.
Please list any learning labels or classifications given to the client:
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.
What, if any, extracurricular activities, sports or lessons does the client participate in:
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.
Behavior

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.

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
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.
If yes, please describe the concerns:
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.
Is there a family history of emotional or behavioral disorders?

Yes No
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.
If yes, please describe.
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.
Please describe the client's specific positive and negative behaviors:
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.
Overall Goals and Plan

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.
Please list behavioral goals and expectations:
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.
What are your academic goals and expectations?
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.
Please indicate who will be working with the client and the amount of time each day (5 days a week) available:
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.
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!!!

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.
What is the main issue that brought you to Little Giant Steps?
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.
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.
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.
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!!"
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.
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.

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.
Signature *

Clear

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.
Please attach a photo of the client:

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.
Should be Empty:

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