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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
Email
1. 
Were you referred to REI by an Authorized REI Provider? If so, please enter their name.

2. 
Please enter the name of the person (Client) for whom we will make the REI Custom Program.

3. 
Please enter the Client's date of birth.

4. 
Please enter the Client's gender.

5. 
Please describe the Client's behaviors and issues.

6. 
Please describe the areas that you would like to address with the REI Custom Program.

7. 
Please list any medication the Client is taking.

8. 
Please list any therapies the Client is undergoing.

1 out of 13
9. 
Trouble sitting still; restless or fidgety.

10. 
Wakes frequently at night.

11. 
Impulsive; often acts without thinking.

12. 
Avoids eye contact.

13. 
Anxious.

14. 
Slow to wake-up after sleep.

15. 
Easily distracted.

16. 
Trouble transitioning from one activity to another.

17. 
Trouble falling asleep.

18. 
Resists physical contact.

19. 
Repeats words or sounds.

2 out of 13
20. 
Irritable or whiny.

21. 
Bothered by certain sounds.

22. 
Repetitive body movements.

23. 
Physically injures self.

24. 
Trouble staying on task.

25. 
Shakes or flaps hands or arms.

26. 
Boisterous.

27. 
Bullies others.

28. 
Poor appetite; doesn't want to eat.

29. 
Often has headaches.

30. 
Rocks body repeatedly; seeks calm by rocking.

31. 
Mood changes often.

3 out of 13
32. 
Unhappy most of time.

33. 
Disrupts others.

34. 
Worries excessively.

35. 
Doesn't follow or ignores instructions.

36. 
Odd behaviors.

37. 
Doesn't finish things.

38. 
Has to have own way.

39. 
Becomes frustrated easily.

40. 
Eats excessively, or would like to, especially when stressed.

41. 
Often has stomach aches.

42. 
Afraid of new things, places or people.

43. 
Chews or sucks on things.

4 out of 13
44. 
Controlling; needs to run things.

45. 
Eats a limited diet; only likes certain foods.

46. 
Inactive, listless.

47. 
Hard to reach; preoccupied.

48. 
Seeks Isolation.

49. 
Communicates only through gestures.

50. 
Moves around aimlessly.

51. 
Doesn't get along well with others.

52. 
Bothered by clothes against skin.

53. 
Currently has seizures that are not controlled by medication.

54. 
Clumsy, uncoordinated.

55. 
Doesn't follow rules.

5 out of 13
56. 
Forgets things.

57. 
Trouble finding the right words to say.

58. 
Moody.

59. 
Picks at self or clothing.

60. 
Often retreats in own world.

61. 
Physically abusive toward others.

62. 
Hears things others don't.

63. 
Poor spelling.

64. 
Often interrupts conversations.

65. 
Trouble hearing in noisy environments.

66. 
Misunderstands often.

67. 
Trouble beginning an activity.

6 out of 13
68. 
Difficulty stopping an activity.

69. 
Gets lost in conversations; responds inappropriately.

70. 
Recurring obsessive thoughts.

71. 
Uncontrollable body movements.

72. 
Often verbally threatening.

73. 
Calmed from pressure against body.

74. 
Lacks motivation.

75. 
Easily overwhelmed by noisy environments.

76. 
Easily startled.

77. 
Easily bored.

78. 
Quick temper; easily angered.

79. 
Fear or panic for no known reason.

80. 
Very sensitive to other people's feelings.

7 out of 13
81. 
Sees things others don't, such as shadows, colors, or objects moving.

82. 
Poor balance.

83. 
Sleeps too much (or would like to given the chance).

84. 
Feelings of hopelessness, helplessness, negativity.

85. 
History of seizure activity that is currently inactive or controlled by medication.

86. 
Fixates on a thought, activity or object.

87. 
Confuses similar sounding words.

88. 
Talks loudly.

89. 
Low self-esteem.

90. 
Difficulty telling which direction a sound came from.

91. 
Experiences uncontrollable vocalizations.

92. 
Verbally abusive toward others.

93. 
Difficulty understanding abstract ideas.

8 out of 13
94. 
Poor penmanship.

95. 
Has trouble with time (always late, etc.).

96. 
Procrastinates.

97. 
Misinterprets others' comments. Takes things the wrong way.

98. 
Negative outlook on life.

99. 
Often has ringing in ears.

100. 
Feels the world is against them.

101. 
Recoils from touch; tactically defensive.

102. 
Makes the same mistakes repeatedly; doesn't seem to learn from mistakes.

103. 
Doesn't seem to know where body is; bumps into things and people.

104. 
Has difficulty making decisions.

9 out of 13
105. 
Has thoughts of harming self (including suicide).

106. 
Trouble grasping the 'big picture'.

107. 
Argumentative; oppositional.

108. 
Disorganized.

109. 
Often loses things.

110. 
Often tired, sluggish, slow moving.

111. 
Repeated negative thoughts.

112. 
Periods of confusion.

113. 
Often lacks the ability to see options.

114. 
Extreme cyclic changes in mood (very high to very low).

115. 
Trouble making changes in action; gets locked into an action and can't change course.

116. 
Frequently experiences deja vu (feelings of experiencing the same thing before).

117. 
Paranoid.

10 out of 13
118. 
Dislikes change.

119. 
Talks very fast.

120. 
Occasionally hears voices in head.

121. 
History of head injury.

122. 
History of brain damage.

123. 
Often displays grandiose thinking.

124. 
Trouble following through on tasks, activities, making goals.

125. 
Fearful of specific things (snakes, spiders, heights, people).

126. 
Experiences frequent changes in sleep patterns.

127. 
Thoughts of hurting others.

128. 
Holds grudges.

129. 
Lacks empathy; has trouble understanding others' feelings.

130. 
Difficulty planning (tasks, activities, making goals).

131. 
Thinks in terms of 'black and white'; trouble seeing nuances in situations.

132. 
Difficulty understanding/identifying own feelings.

11 out of 13
133. 
Bothered by/sensitive to lights.

134. 
Adopted as a young child.

135. 
Aggressive to others.

136. 
Avoids going to noisy places such as restaurants, theaters, malls.

137. 
Prefers music, videos or TV too loud.

138. 
Often oblivious to certain sounds.

139. 
Misunderstands often; asks “what” a lot.

140. 
Difficulty judging how much to extend and flex muscles when dressing or during other activities.

141. 
Uses too much force when handling objects; slams doors, spills cup, breaks objects such as toys, etc.

142. 
Trouble judging the weight of an object; can’t tell the difference between two objects' weights.

143. 
Prefers tight-fitting clothes.

144. 
Seeks out highly physical activities involving bumping, jumping, or crashing into things.

145. 
Loves wrestling and tackling.

146. 
Responds negatively to light or unexpected touch.

147. 
Highly sensitive to minor bumps, bruises, cuts.

12 out of 13
148. 
Dislikes getting messy.

149. 
Doesn’t like washing face, brushing hair, or brushing teeth.

150. 
Unresponsive or under responsive when touched.

151. 
Repeatedly touches surfaces or seeks rough textures to touch.

152. 
Enjoys objects or activities with a strong sensory input.

153. 
Unable to identify objects by touch, including shape, texture, temperature or size.

154. 
Messy dresser; doesn’t care or seem to be aware of how clothes are hanging.

155. 
Fearful of walking on stairs or uneven ground.

156. 
Easily startled when unexpectedly moved or touched by someone.

157. 
Craves intense, fast-moving activities.

158. 
Enjoys spinning, swinging or bouncing and has difficulty stopping these activities.

159. 
Has a limp body; slumps while sitting.

160. 
Easily fatigued; tires easily.

161. 
Poor gross motor skills; difficulty catching, climbing, jumping.

13 out of 13

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Disclaimer: Brain Stim Audio is for entertainment purposes only and is not intended to diagnose, treat, cure or prevent any disease or mental disorder. It is also not a substitute for a qualified doctor’s or mental health professional’s care.

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