intake4-11 - Brain Stim Audio

REI Custom Program Intake for Children Ages 4-11

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

Were you referred to REI by an Authorized REI Provider? If so, please enter their name.

Please enter the name of the person (Client) for whom we will make the REI Custom Program.

Please enter the Client's date of birth.

Please enter the Client's gender.

Female Male

Please describe the Client's behaviors and issues.

Please describe the areas that you would like to address with the REI Custom Program.

Please list any medication the Client is taking.

Please list any therapies the Client is undergoing.

1 out of 13

Trouble sitting still; restless or fidgety.