intake0-3 - Brain Stim Audio

REI Custom Program Intake for Children Birth to 3

Please complete and submit the intake, We will place your first REI Custom Program track in your account within 24 hours.

Call us at 800-659-6644 or email us at contact@stronginstitute.com with any questions.

Instructions

Please select a rating for each of the following questions. Refer to behavior for the past 3 months. For each item, decide whether the behavior is relevant and to what degree.

Not relevant = You never see this behavior
Slightly relevant = You rarely see this behavior
Pretty relevant = You occasionally see this behavior
Very relevant = You often see this behavior

Remember: Don’t think too hard about the answer — your first reaction is usually the right one.

Name of Contact Person

Injures self.

Not relevant Slightly relevant Pretty relevant Very relevant

Wakes frequently at night.

Not relevant Slightly relevant Pretty relevant Very relevant

Avoids eye contact.

Not relevant Slightly relevant Pretty relevant Very relevant

Has trouble understanding verbal instructions.

Not relevant Slightly relevant Pretty relevant Very relevant

Slow to wake-up after sleep.

Not relevant Slightly relevant Pretty relevant Very relevant

Easily distracted.

Not relevant Slightly relevant Pretty relevant Very relevant

Trouble transitioning from one activity to another.

Not relevant Slightly relevant Pretty relevant Very relevant

Trouble falling asleep.

Not relevant Slightly relevant Pretty relevant Very relevant

Resists physical contact.

Not relevant Slightly relevant Pretty relevant Very relevant

10.

Repeats words or sounds.

Not relevant Slightly relevant Pretty relevant Very relevant

11.

Irritable or whiny.

Not relevant Slightly relevant Pretty relevant Very relevant

12.

Bothered by certain sounds.

Not relevant Slightly relevant Pretty relevant Very relevant

1 out of 7

13.

Repetitive body movements.

Not relevant Slightly relevant Pretty relevant Very relevant

14.

Excessively active (running, jumping).

Not relevant Slightly relevant Pretty relevant Very relevant

15.

Shows no interest in others.

Not relevant Slightly relevant Pretty relevant Very relevant

16.

Can't communicate wants or needs.

Not relevant Slightly relevant Pretty relevant Very relevant

17.

Verbal skills below age level.

Not relevant Slightly relevant Pretty relevant Very relevant

18.

Has trouble focusing at age level.

Not relevant Slightly relevant Pretty relevant Very relevant

19.

Shakes or flaps hands or arms.

Not relevant Slightly relevant Pretty relevant Very relevant

20.

Unresponsive when spoken to.

Not relevant Slightly relevant Pretty relevant Very relevant

21.

Throws tantrums excessive for age.

Not relevant Slightly relevant Pretty relevant Very relevant

22.

Excessive vocalizations.

Not relevant Slightly relevant Pretty relevant Very relevant

23.

Has poor appetite, doesn't want to eat.

Not relevant Slightly relevant Pretty relevant Very relevant

24.

Rocks body repeatedly; Seeks calm by rocking.

Not relevant Slightly relevant Pretty relevant Very relevant

2 out of 7

25.

Cries easily.

Not relevant Slightly relevant Pretty relevant Very relevant

26.

Mood changes often.

Not relevant Slightly relevant Pretty relevant Very relevant

27.

Seems unhappy most of time.

Not relevant Slightly relevant Pretty relevant Very relevant

28.

Plays with toys inappropriately.

Not relevant Slightly relevant Pretty relevant Very relevant

29.

Has odd behaviors.

Not relevant Slightly relevant Pretty relevant Very relevant

30.

Becomes frustrated easily.

Not relevant Slightly relevant Pretty relevant Very relevant

31.

Screams for seemingly no reason.

Not relevant Slightly relevant Pretty relevant Very relevant

32.

Afraid of new things, places or people.

Not relevant Slightly relevant Pretty relevant Very relevant

33.

Chews or sucks on things.

Not relevant Slightly relevant Pretty relevant Very relevant

34.

Eats limited diet, only likes certain foods.

Not relevant Slightly relevant Pretty relevant Very relevant

35.

Inactive, listless.

Not relevant Slightly relevant Pretty relevant Very relevant

36.

Hard to reach, preoccupied.

Not relevant Slightly relevant Pretty relevant Very relevant

3 out of 7

37.

Seeks isolation.

Not relevant Slightly relevant Pretty relevant Very relevant

38.

Moves around aimlessly.

Not relevant Slightly relevant Pretty relevant Very relevant

39.

Disobedient.

Not relevant Slightly relevant Pretty relevant Very relevant

40.

Prefers the company of adults.

Not relevant Slightly relevant Pretty relevant Very relevant

41.

Doesn’t communicate wants or needs.

Not relevant Slightly relevant Pretty relevant Very relevant

42.

Bothered by clothes against skin.

Not relevant Slightly relevant Pretty relevant Very relevant

43.

Has Seizures.

Not relevant Slightly relevant Pretty relevant Very relevant

44.

Clumsy, uncoordinated.

Not relevant Slightly relevant Pretty relevant Very relevant

45.

Doesn't follow rules.

Not relevant Slightly relevant Pretty relevant Very relevant

46.

Misunderstands often.

Not relevant Slightly relevant Pretty relevant Very relevant

47.

Trouble beginning an activity.

Not relevant Slightly relevant Pretty relevant Very relevant

48.

Difficulty stopping an activity.

Not relevant Slightly relevant Pretty relevant Very relevant

4 out of 7

49.

Traumatic birth experience.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

50.

Frequent ear infections.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

51.

Low self-esteem.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

52.

Uncontrollable body movements.

Not relevant Slightly relevant Pretty relevant Very relevant

53.

Calmed from pressure against body.

Not relevant Slightly relevant Pretty relevant Very relevant

54.

Easily overwhelmed by noisy environments.

Not relevant Slightly relevant Pretty relevant Very relevant

55.

Easily startled.

Not relevant Slightly relevant Pretty relevant Very relevant

56.

Fear or panic for no known reason.

Not relevant Slightly relevant Pretty relevant Very relevant

57.

Poor balance.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

58.

History of seizure activity that is currently inactive or controlled by medication.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

59.

Difficulty telling which direction a sound came from.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

60.

Very sensitive to other people's feelings.

Not relevant Slightly relevant Pretty relevant Very relevant

5 out of 7

61.

Adopted.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

62.

Born prematurely.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

63.

Recoils from touch; tactically defensive.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

64.

Often tired, sluggish, slow moving.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

65.

Dislikes change.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

66.

History of head injury.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

67.

History of brain damage.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

68.

Fearful of specific things (snakes, spiders, heights, people).

Not relevant

Slightly relevant

Pretty relevant

Very relevant

69.

Experiences frequent changes in sleep patterns.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

70.

Bothered by/sensitive to lights.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

71.

Doesn't seem to know where body is; bumps into things and people.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

72.

Aggressive to others.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

6 out of 7

73.

Avoids going to noisy places such as restaurants, theaters, malls.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

74.

Often oblivious to certain sounds.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

75.

Difficulty judging how much to extend and flex muscles when dressing or during other activities.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

76.

Trouble judging the weight of an object; can’t tell the difference between two objects' weights.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

77.

Prefers tight-fitting clothes.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

78.

Seeks out highly physical activities involving bumping, jumping, or crashing into things.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

79.

Responds negatively to light or unexpected touch.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

80.

Doesn’t like washing face, brushing hair, or brushing teeth.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

81.

Unresponsive or under responsive when touched.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

82.

Easily startled when unexpectedly moved or touched by someone.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

83.

Enjoys spinning, swinging or bouncing and has difficulty stopping these activities.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

84.

Highly sensitive to minor bumps, bruises, cuts.

Not relevant

Slightly relevant

Pretty relevant

Very relevant

7 out of 7

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