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Learning Style Profile

To arrange for you free consultation, please complete the attached form as accuarately as possible. While some choices may not apply exactly, please check the answers that best fit your situation. 

Name of Parent(s)  
 or Guardian(s) (req'd 
if Client is under 18):  
Primary Email Address:  
Home phone:  
Cell phone:  
Work phone:  
Address 1:  
Address 2:  
City:  
State:  
Zip:  
Country:  
Fax:  
Client Name:  
Client Age:  
Client Date of Birth:  
Please provide a brief description of the current struggle(s) that the Client is experiencing.

Please select (check) all that apply to the client's current struggles:
Difficulty with Reading Difficulty with Math
Slow Reader Has trouble self-starting
Dislikes Reading Difficulty completing homework
Poor Reading Comprehension Fails to hand in assignments
Poor Spelling Difficulty finishing projects
Poor handwriting Test anxiety or nervousness
Difficulty with writing/composition Dislikes school
Difficulty memorizing vocabulary Suspect Dyslexia
Difficulty memorizing multiplication table Suspect ADD or ADHD

Please select (check) all that apply:
Excellent Reader (above Grade level) Enjoys skateboarding, snowboarding, skiing, BMX'ing or similar activities
Excellent at Math (above grade level) Enjoys video or computer games
Enjoys Reading Good at remembering where things are
Enjoys Math Good at puzzles
Enjoys Science Above average intelligence
Enjoys History or Social Studies Enjoys learning
Enjoys physical activity Very social
Enjoys Art Good at multi-tasking
Enjoys music  Other

Please describe any other talents or abilities demonstrated by the client:
Please describe any other interests, activities or areas of study that the client enjoys:

Please select (check) all that apply to the client's current struggles:
Delayed speech or language skills  Fear of school or work
Avoids eye contact Fear of social situations or groups
Difficulty following instructions Fear of heights or bridges
Generally or often inattentive Fear of the Dark
Sensative to clothing or touch Other Fears or Phobias
Over reacts to changes in routine or schedule Frequent bedwetting
Sensative to criticism Frequent nightmares or night terrors
Difficulty sleeping Alergies
Poor Diet, over or under weight Frequent headaches or migraines
Low self-esteem Obsessive or Compulsive behaviors

Please describe any behavior or emotional issues that you feel might be relevant:
In your own words, please describe any significant emotional events during the most recent 3 years:

Is the client currently under the care of a physician, psychotherapist, pathologist or licensed medical practitioner? 
 If yes, please explain the condition(s) for which the client is being treated and the nature of the treatment(s), including any medications.

Please include any additional information which you believe may be relevant to the current struggle(s):
Please describe as clearly as possible the results that you (the client) would like to achieve.

How did you hear about  us?

Thank you for completing your information profile. Please take a moment to review your answers and add any information that you feel is relevant to achieving your desired results.