Child Evaluation

Name of Parents/Guardians

Mobile Number(s)

Address

Street Address

Street Address Line 2

CityCounty

Post CodeCountry

Email

example@example.com

Name of Child

Child's Date of Birth

How did you hear about Performance Breakthrough?

Please read the list of possible difficulties below, then click under the option which applies most to your child.

Selecting ‘Never’ indicates that your child has no difficulty with the task.

Selecting ‘Always’ indicates that your child has great difficulty with the task.

Rows	Never	Sometimes	Always
Getting ready for school
Remembering:Books/PE Gear/lunches
Doing homework
Reciting the months of year in order
Learning spellings
Retaining spellings after the Friday test
Writing a story Is it as short as possible?
Studying for tests
Recognising mistakes when writing
Has an attitude to homework of 'it will do'
Copying from board
Reading- is it slow and monotone?
Difficulty reading out loud
Do words move about on the page?
Are b's and d's or numbers switched the wrong way
Difficulty writing a story that makes sense
Remembering capital letters and full stops
Handwriting. Is it messy?
Difficulty writing on a straight line
Squeezes words in to the end of the line
Lack of spacing/letters random sizes
Speech difficulties - pronunciation
Learning times tables
Difficulty waiting in turn (in a queue)
Interrupts when you're speaking to others
Tired just sitting up straight - Do they slouch?
Fidgets with hands or feet
Moves around alot when seated
Easily distracted/low concentration
Is 'on the go' or acts as if 'driven by a motor'
Slow processing speed
Following instructions
Talks excessively
Runs about or climbs excessively
Throwing and/or catching
Difficulty riding a bike
Awkward when running
Has a tendency to knock glasses over
Difficulty playing in team sports
Awkward pen grip
Struggles to tie shoe laces
Difficulty getting to sleep
Fussy eater
Gets frustrated easily over little things
Shows aggressive behaviour (Meltdowns)
Gets anxious
Inappropriate speech/no filter
Difficulty expressing emotions
Very dependent on specific routines
Difficulty holding eye contact
Fixations
Seems not to listen when spoken to directly
Low confidence
Prefers to play alone
Is keeping friendsdifficult?
Knows what to say but can't get the words out
No consequences of actions
Lack of empathy
Finds it hard to regulate emotions
Sensitive to clothes -. socks, pants, jeans, labels
Feels a light touch but not a deep impact
Sensitive to loud noises
Sensitive to smells or no sense of smell

Please let us know what your 3 main areas of concern are:

Please detail any pre-existing conditions that would render it difficult to stand on a balance board?

Please click 'Submit' below to return your completed form to Performance Breakthrough before your Evaluation appointment.

If you still need to book you appointment, please contact us to arrange a suitable time.

Tel: 028 9036 4000 / 07790 245 145

Email: info@performancebreakthrough.co.uk

www.performancebreakthrough.co.uk

By clicking 'Submit' you are confirming that you have received and read the below information in relation to how our data is held by Performance Breakthrough Ltd. If you do not want to confirm and agree to this information, please let us know separately by email.

Data Privacy Policy

As a company Performance Breakthrough Ltd uphold the laws of GDPR.

The information we will hold will be held on the following mediums:-

A record card detailing the name of the participant in the programme, the parent’s name(s), address, contact numbers, email address, the date you started the programme and dates of review appointments. This information will not be shared with anyone or any other organisation unless requested by you.
An Evaluation Form which will detail the symptoms you or your child are experiencing before you start the programme. This evaluation will be updated at 3-month intervals. The quantifiable results of progress will be collated anonymously and used for research and evidence purposes.
Testmonials / Quotations detailing the positive areas of progress. We may use these for marketing purposes, but only with your prior consent.
Video clips showing progress. We will only take a video clip with your prior consent. We may use these for marketing purposes, but only with your prior consent.
A Receipt Copy detailing the name of the payer, address, contact number and email address. This information will not be share with anyone or any other organisation unless requested by you.

Your email address will not be shared with anyone or any other company and will only be used for communication, updates and a review survey between Performance Breakthrough Ltd and you.