The Learning Center Intake Form Step 1 of 25 4% Student Name(Required) First Name Last Name Student's Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth(Required) MM slash DD slash YYYY Sex(Required) Male Female Age(Required)Please enter a number from 0 to 21.Grade(Required)Please enter a number from 0 to 12.Phone(Required)School History (list in order of attendance)Please include School Name, City, Grades & Dates Attended.If adopted, please provide age & brief circumstances Who referred your student to The Learning Center?(Required) Do we have permission to release information to your referring professional when necessary or appropriate?(Required) Yes No Name of parent/guardian completing this form(Required) First Name Last Name Email of parent/guardian(Required) Date form is being completed(Required) MM slash DD slash YYYY Family HistoryFirst Parent/Guardian's Name First Name Last Name Marital StatusMarriedDivorcedSeparatedOtherAddress (if different from student) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone NumberEmail Any history of learning disabilities? Yes No If yes, please explainSecond Parent/Guardian's Name First Name Last name Marital StatusMarriedDivorcedSeparatedOtherAddress (if different than student) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone NumberEmail Any history of learning disabilities? Yes No If yes, please explainPlease list sibling information (Include name, age, grade, & any learning/developmental issues)What is the main language spoken at home? Any other languages spoken at home? Are there any stresses involved with the student's living situation? Concerns & ExpectationsWhat main concern brings you to us?When did you begin to become concerned and why?What is the student's feelings about coming here?What is the student's understanding of why you are here today?What is your expectation as a result of therapy with us? School HistoryHas the student received any formal educational evaluation or special academic/behavioral therapy? Yes No If yes, please indicate the type of service (psychotherapy, speech/lauguage, OT, PT, etc), school/agency which rendered the service and the date:(Required)If the student has a 504 or IEP please indicate the date Please specify 504 or IEP and date of most recent.Please indicate any evaluations (educational/psychological/neurological, etc)Include type of testing, agency/location, examiner, phone, date. Medical History - PregnancyPlease explain any difficulties or complications during pregnancy or deliveryWhat drugs or alcohol were used during pregnancy Was the baby full term? Yes No List any medications or supplements taken during pregnancyExplain any history of head trauma relating to the student. Medical History - Overall & DevelopmentalList any current medical conditions (epilepsy, allergies, chronic illnesses, etc)Glasses/contacts needed? Yes No Other If other Hearing Aid/Cochlear Implants? Yes No Other If other Please list any childhood illnessesWere there any high fevers or convulsions? Yes No Were there any head injuries or loss of consciousness? Yes No List regular medications takenInclude type, frequency, side effects).Does your child have difficulty sleeping? Yes No Other If other Please describe your child's appetite and any food allergiesDescribe coordination problems you have seenDate of most recent physical MM slash DD slash YYYY Date of most recent eye exam MM slash DD slash YYYY Date of most recent hearing exam MM slash DD slash YYYY Check any of the developmental milestones which were late for the student Babbling (4-6 mo) Imitating sounds (7mos-1yr) Speaks 2-3 words, pretends to read, scribbles (1-2 yrs)) Sentence use, begins sound to letter, symbols to letters (3-4yrs) Recognize some print, tells main idea, rhyming/alphabet (4-5yrs) Writing with structure, reading independently, understand figure of speach (6-8yrs) Social Emotional HealthDescribe any emotional/behavioral problems the student has experienced.Describe the student's attitude toward (1) their siblings, (2) peers or playmates.List the student's favorite activities/hobbiesList the student's favorite school subjectsHow many days on average does the student miss from school?Per school year.Is the student involved in any community service programs?If yes, please describe.Has the student made a profession of faith in Christ? Yes No Other If other Which describes the student's relationship to Biblical principles? Antagonistic toward Christianity Interested in learning Visible/steady growth Is the student part of a local church youth group? Yes No From the list, which is most likely to explain the student's view of authority? Do what you're told... Let's make a deal... Be considerate, nice and kind, amd you'll get along with people. Everyone in society is obligated and protected by the law. Academic SymptomsSelect the choice that best describes the frequency each symptom has appeared in the student:Reading: Decoding deficitsChoose OneNeverSeldomSometimesOftenAlwaysReading: Comprehension problemsChoose OneNeverSeldomSometimesOftenAlwaysReading: Rate/fluency below grade levelChoose OneNeverSeldomSometimesOftenAlwaysWriting: Composition or structural deficitsChoose OneNeverSeldomSometimesOftenAlwaysWriting: Organizational deficitsChoose OneNeverSeldomSometimesOftenAlwaysMath: Unable to solve word problemsChoose OneNeverSeldomSometimesOftenAlwaysMath: ReasoningChoose OneNeverSeldomSometimesOftenAlwaysMath: Computation (unable to complete process)Choose OneNeverSeldomSometimesOftenAlways Executive Functioning SymptomsSelect the choice that best describes the frequency each symptom has appeared in the student:Poor organizational skillsChoose OneNeverSeldomSometimesOftenAlwaysPoor working memory (forgets where puts things)Choose OneNeverSeldomSometimesOftenAlwaysPoor study habits or study skillsChoose OneNeverSeldomSometimesOftenAlwaysSocial Emotional SymptomsSuffers from depressionChoose OneNeverSeldomSometimesOftenAlwaysSuffers from anxiety or panic attacksChoose OneNeverSeldomSometimesOftenAlwaysStruggles with self-discipline or self-controlChoose OneNeverSeldomSometimesOftenAlwaysIs overly negativeChoose OneNeverSeldomSometimesOftenAlwaysHas low overall motivationChoose OneNeverSeldomSometimesOftenAlwaysAdoption issuesChoose OneNeverSeldomSometimesOftenAlwaysWould rather be aloneChoose OneNeverSeldomSometimesOftenAlwaysAdjusting to stress (divorce, death in family)Choose OneNeverSeldomSometimesOftenAlwaysHas a negative view of selfChoose OneNeverSeldomSometimesOftenAlways Visual Screening SymptomsHeadaches when reading or writingChoose OneNeverSeldomSometimesOftenAlwaysWords slide together or blur when readingChoose OneNeverSeldomSometimesOftenAlwaysReads below grade levelChoose OneNeverSeldomSometimesOftenAlwaysLoses place while readingChoose OneNeverSeldomSometimesOftenAlwaysTilts head or closes an eye when readingChoose OneNeverSeldomSometimesOftenAlwaysExperiences difficulty copying from the boardChoose OneNeverSeldomSometimesOftenAlwaysDoes not like reading or writingChoose OneNeverSeldomSometimesOftenAlwaysLeaves out small words when readingChoose OneNeverSeldomSometimesOftenAlwaysIt's difficult to write in a straight lineChoose OneNeverSeldomSometimesOftenAlwaysBurning, itching or watery eyesChoose OneNeverSeldomSometimesOftenAlwaysHas difficulty understanding what they've readChoose OneNeverSeldomSometimesOftenAlwaysHolds book very close to their faceChoose OneNeverSeldomSometimesOftenAlwaysDifficulty paying attention when readingChoose OneNeverSeldomSometimesOftenAlwaysDifficulty completing assignments on timeChoose OneNeverSeldomSometimesOftenAlwaysGives up easily "I can't" before tryingChoose OneNeverSeldomSometimesOftenAlwaysBumps into things, knocks things overChoose OneNeverSeldomSometimesOftenAlwaysHomework takes longer than typicalChoose OneNeverSeldomSometimesOftenAlwaysDifficulty staying on task in schoolChoose OneNeverSeldomSometimesOftenAlwaysDaydreamsChoose OneNeverSeldomSometimesOftenAlways Primitive Reflex Group 1: Fear Paralysis ReflexLow stress toleranceChoose OneNeverSeldomSometimesOftenAlwaysFears separationChoose OneNeverSeldomSometimesOftenAlwaysGives up easily, fears failureChoose OneNeverSeldomSometimesOftenAlwaysAvoids new situations or peopleChoose OneNeverSeldomSometimesOftenAlwaysFreezes upChoose OneNeverSeldomSometimesOftenAlwaysPanic attack and phobiasChoose OneNeverSeldomSometimesOftenAlwaysLacks motivation, overly dependentChoose OneNeverSeldomSometimesOftenAlwaysThrows temper tantrums or is aggressiveChoose OneNeverSeldomSometimesOftenAlways Primitive Reflex Group 2: Moro ReflexMotion sickness, poor balance or coordinationChoose OneNeverSeldomSometimesOftenAlwaysPoor stamina, tires easilyChoose OneNeverSeldomSometimesOftenAlwaysAvoids eye contactChoose OneNeverSeldomSometimesOftenAlwaysSensitive to light, touch or soundChoose OneNeverSeldomSometimesOftenAlwaysAllegies, chronic illnessChoose OneNeverSeldomSometimesOftenAlwaysCraving sweetsChoose OneNeverSeldomSometimesOftenAlwaysDislikes change or surprisesChoose OneNeverSeldomSometimesOftenAlwaysAnxiety or mood swingsChoose OneNeverSeldomSometimesOftenAlwaysPoor math senseChoose OneNeverSeldomSometimesOftenAlwaysShy in social settingsChoose OneNeverSeldomSometimesOftenAlwaysEmotionally and socially immatureChoose OneNeverSeldomSometimesOftenAlwaysStressful birthChoose OneNeverSeldomSometimesOftenAlways Primitive Reflex Group 3: Tonic Labyrinthine ReflexPoor posture, may walk on toesChoose OneNeverSeldomSometimesOftenAlwaysWeak musclesChoose OneNeverSeldomSometimesOftenAlwaysPoor balanceChoose OneNeverSeldomSometimesOftenAlwaysUnable to easily cross eyes or hurts when crossingChoose OneNeverSeldomSometimesOftenAlwaysSpatial problems - bumps into things, no personal spaceChoose OneNeverSeldomSometimesOftenAlwaysPoor sequencing - telling stories, counting, organizingChoose OneNeverSeldomSometimesOftenAlwaysPoor sense of time, unable to read analog clockChoose OneNeverSeldomSometimesOftenAlwaysSlow copying from board/bookChoose OneNeverSeldomSometimesOftenAlwaysPoor organizational skillsChoose OneNeverSeldomSometimesOftenAlwaysDifficulty tracking when readingChoose OneNeverSeldomSometimesOftenAlwaysDislikes sportsChoose OneNeverSeldomSometimesOftenAlwaysFalls frequentlyChoose OneNeverSeldomSometimesOftenAlways Primitive Reflex Group 4: Spinal Galant ReflexFidgetingChoose OneNeverSeldomSometimesOftenAlwaysBedwettingChoose OneNeverSeldomSometimesOftenAlwaysPoor concentration or attentionChoose OneNeverSeldomSometimesOftenAlwaysPoor working memory, can't follow multi-step directionsChoose OneNeverSeldomSometimesOftenAlwaysFive senses are hypersensitiveChoose OneNeverSeldomSometimesOftenAlwaysDifficulty reading, poor phonemic awarenessChoose OneNeverSeldomSometimesOftenAlwaysDiagnosed with auditory processing disorderChoose OneNeverSeldomSometimesOftenAlwaysMakes noises when sittingChoose OneNeverSeldomSometimesOftenAlways Primitive Reflex Group 5: Asymmetrical Tonic Neck ReflexPoor handwritingChoose OneNeverSeldomSometimesOftenAlwaysEyes jump over words, lines or repeat when readingChoose OneNeverSeldomSometimesOftenAlwaysPoor balanceChoose OneNeverSeldomSometimesOftenAlwaysRight-left confusion, poor sense of directionChoose OneNeverSeldomSometimesOftenAlwaysLetter, number reversalsChoose OneNeverSeldomSometimesOftenAlwaysDifficulty crossing midlineChoose OneNeverSeldomSometimesOftenAlwaysDifficulty copyingChoose OneNeverSeldomSometimesOftenAlwaysDifficulty with spellingChoose OneNeverSeldomSometimesOftenAlwaysPoor expression of ideas on paperChoose OneNeverSeldomSometimesOftenAlwaysMixed laterality - uses both handsChoose OneNeverSeldomSometimesOftenAlways Primitive Reflex Group 6: Symmetrical Tonic Neck ReflexPoor postureChoose OneNeverSeldomSometimesOftenAlwaysSlumps when walking and sittingChoose OneNeverSeldomSometimesOftenAlwaysSits on legs in a W positionChoose OneNeverSeldomSometimesOftenAlwaysDifficulty with fine and gross motor skillsChoose OneNeverSeldomSometimesOftenAlwaysMessy eaterChoose OneNeverSeldomSometimesOftenAlwaysDifficulty with eye trackingChoose OneNeverSeldomSometimesOftenAlwaysSlow when copyingChoose OneNeverSeldomSometimesOftenAlwaysPoor attention skillsChoose OneNeverSeldomSometimesOftenAlwaysDifficulty learning to swimChoose OneNeverSeldomSometimesOftenAlwaysClumsinessChoose OneNeverSeldomSometimesOftenAlways Primitive Reflex Group 7: Palmar ReflexPoor handwritingChoose OneNeverSeldomSometimesOftenAlwaysPoor manual dexterityChoose OneNeverSeldomSometimesOftenAlwaysLack of pencil gripChoose OneNeverSeldomSometimesOftenAlwaysSpeech and articulation issuesChoose OneNeverSeldomSometimesOftenAlwaysPalm may be hypersensitive to touchChoose OneNeverSeldomSometimesOftenAlwaysMakes mouth movements when writing or drawingChoose OneNeverSeldomSometimesOftenAlways Release of Information FormName of Student First Name Last Name I hereby release ECA Therapist to discuss pertinent information of the above mentioned student with other educational or therapeutic professionals who work with the student for the purpose of better serving the student. These professionals may include but are not limited to the student's teacher(s), occupational or speech/language therapist(s), psychologist(s) or pediatrician. I understand that any discussions will be handled with the greatest respect for the individual and the individual's privacy. I further understand that any information shared is held in absolute confidence between ECA Therapist and said professionals. I understand that I may at any time withdraw permission to share the student's information with educational or therapeutic professions, either jointly or severely at any time, by writing a letter to Eukarya Christian Academy.Signature Date MM slash DD slash YYYY Relationship to student Emergency InformationName of Student First Name Last Name Name of Physician First Name Last Name Physician's Phone NumberPhysician's Phone NumberHospital Phone Number Pertinent Medical HistoryAllergies Emergency ContactNamePhoneRelationship Add RemoveIn the event that a parent/guardian of a family member can not be reached, I give my permission for the student to receive the necessary medical services and/or to call an ambulance. The undersigned person(s) will be responsible for medical/ambulance expenses.Signature Date MM slash DD slash YYYY Relationship to student Business PoliciesI. CommitmentIn order to achieve the goals we have established, we strongly encourage consistent attendance. While we understand that there are times life gets busy, your child will experience the best results by coming to all planned sessions on time and for the complete duration. II. CancellationsIf you give at least twenty-four hour notice, you will not be charged for canceling a session. Without twenty-four hour notice, payment for the missed session will be invoiced. If you are late for a session, the session will still end at the appointed time and you will still be charged for a full session. If the therapist is ill or unavailable for a session, the client will be notified as soon as possible and will have the option of making up the session or crediting the missed session to the next billing. III. Payment SchedulePayment is expected prior to service rendered based on a payment plan agreement made with Eukarya Christian Academy. IV. HolidaysHolidays will be indicated on the Eukarya Christian Academy School Calendar. Other vacation times will be arranged at the discretion of the Educational Therapist. Ample notice will be provided. V. End of ServicesEducational therapy forms a strong relationship between student and educational therapist. Abrupt termination of services damages that relationship and can be hurtful to a child. Thus, when parents decide that it is time to end services for any reason, four weeks notice is required. This is to allow for final assessments and to allow for closure between student and educational therapist. Consent(Required) I have read, understand and agree to abide by the five points of the business policy for Eukarya Christian Academy.Signature(Required) Date(Required) MM slash DD slash YYYY Print Name(Required) First Name Last Name Services and Schedule of FeesEukarya Christian Academy takes pride in the personalized, research-based support we can offer your child. Helping your child feel confident and to love learning is our goal. A licensed dyslexia therapist will personally guide your child through a multisensory program of explicit, systematic instruction for both reading and spelling. These programs are clinically diagnostic and prescriptive, multisensory, intensive, and results driven. For dyslexia, effective interventions should include training in letter sounds, phoneme awareness, and linking letters and phonemes through writing and reading from texts at the appropriate level to reinforce emergent skills. Your child can work with a reading specialist to learn how to: Sound out letters and words ("phonics") Read more quickly Increase comprehension Write more clearly A couple of reading programs that are geared toward kids with dyslexia: Orton-Gillingham: This is a step-by-step technique that teaches kids how to match letters with sounds, and recognize letter sounds in words. Multisensory instruction: Teaches kids how to use all of their senses - touch, sight, hearing, smell, and movement - learn new skills. For example, your child might run their finger over letters made from sandpaper to learn how to spell. Dyscalculia: A trained specialist will work with your student to identify this learning challenge and provide remediation. Persons with dyscalculia have marked, persistent problems applying the basic methods of arithmetic and in knowledge of math facts (the multiplication table). These problems are not due to low intelligence or inadequate schooling, but are often associated with impaired basic processing of numbers and quantities.ECA students: Initial Intake/assessment = $50/hr ($150 max) Individual sessions = $50 Group of 2-3 students = $35 Non-ECA students: Initial Intake/assessment = $50/hr ($150 max) Individual sessions = $55 Group of 2-3 students = $40 *ALL sessions are 50 minutes. Includes quarterly meetings with parents and case management. Behavioral Therapy:Initial Intake/Assessment: Includes consultation with students, parents, teachers, student's doctors and psychologists to assess student's current social-emotional functioning and determine appropriate therapeutic strategies and interventions to address needs. Counseling/Behavioral Coaching: Includes individual counseling/coaching and/or group counseling to address social-emotional needs related to anxiety/depression, ADHD/ADD, anger management, impulse control, self-esteem, interpersonal skill deficits.ECA students: Initial Intake/assessment = $50/hr ($150 max) Individual sessions = $45 Group of 2-3 students = $30 Non-ECA students: Initial Intake/assessment = $50/hr ($150 max) Individual sessions = $50 Group of 2-3 students = $35 *ALL sessions are 50 minutes. Includes quarterly meetings with parents and case management. Occupational Therapy:School based occupational therapy practitioners support academic achievement and social participation by promoting occupation within all school routines. Therapy provided within the school setting is designed to enhance the student's abilities to participate in the educational process. Occupational therapists help individuals to do and engage in the specific activities that make up daily life. For children and youth in schools, occupational therapy works to ensure that a student can participate in the full breadth of school activities. Including paying attention in class, concentrating on tasks, appropriate posture, pencil grip, and classroom behavior. Occupational therapists may be recommended for an individual student for reasons that might be affecting his or her learning or behavior, such as motor skills, cognitive processing, visual or perceptual problems, mental health concerns, difficulties staying on task, disorganization, or inappropriate sensory responses. The occupational therapist accesses the child's skills and other problems (including behavior), in addition to his or her visual, sensory, and physical capabilities.A Cognitive Developmental Progam to strengthen cognitive abilities and decreases learning, emotional, and social challenges, to help students achieve their fullest potential. "It is a progressive system of physical, visual, auditory, vestibular, and cognitive exercises meant to strengthen existing neural connections and, more importantly, to create missing neural pathways which may inhibit one's ability to learn." (www.equippingminds.com)Initial (OT or Equipping Minds) Sessions = $120 *Includes observation of student in classroom setting (if appropriate), review of intake form, consultation with student/teacher/parents, formal & informal assessments to determine appropriate plan of care & goals. Individual (OT or Equipping Minds) Sessions = $60 Group of 2-3 students (OT or Equipping Minds) Sessions = $45 Re-Evaluation (OT or Equipping Minds) Sessions = $80 *Reassessment (when appropriate) using formal or informal assessments with established students, as needed, to update goals/progress. Includes meeting with teachers/parents **ALL sessions are 50 minutes. Subject Tutoring:Individual tutoring allows students one on one with a subject specific tutor. Schedule of Fees for Subject Specific Tutoring: ECA students: $35/session Non-ECA students: $45/session *ALL sessions are 50 minutes. Parental Consent to Services & Commitment to FeesConsent(Required) By clicking the submit button, I agree to terms & conditions.(Required)Sessions NOT cancelled within 24 hours will be invoiced at the regular rate. (Unless in the instance of an illness or family emergency). Please make checks out to Eukarya Christian Academy. Please inquire with your insurance company to see if reimbursement is an option. Parents will be invoiced for services on a monthly basis.Content(Required) I have read, understand, and agree to the above stated fees and the conditions of this educational therapy practice.(Required)Name First Name Last Name Signature Date MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
