HISTORY (Birth to present)
VISUAL – please identify any diagnoses received:
AUDITORY - please identify any diagnoses received and testing done:
DIETARY
Please select the option that reflects the client's eating habits:
Describe if there are any concerns in the following areas:
DEVELOPMENTAL - indicate the age in months and years when these developmental steps were achieved:
Indicate if the client engages/enjoys the following activities and time spent per day on each:
Give insight and comments for the following areas:
HAND PREFERENCE - indicate whether right, left or mixed:
ACADEMICS - list current grade level working at and all concerns you have:
BEHAVIOR - note on a scale of no concern, mild, moderate or severe, your level of concern:
Please read and check each of the following statements
Hope And A Future is a self-consciously Christian educational organization. HAAF utilizes an eclectic approach to eliminating learning, motor, developmental and speech inefficiencies. The developmental and educational plans are individualized for each client. Plans are not medical, therapeutic or psychological prescriptions. Plan recommendations are offered for the client and families' review, investigation and education. Application of the plan is the responsibility of the client and family. Neurodevelopmentalists are not licensed to practice medicine. If medical or other licensed professional advice is needed, the family is urged to consult a licensed physician or other licensed professional.
I acknowledge that I have read and completed this information to the best of my knowledge and ability, and that I understand that neither Hope And A Future nor those trained by or employed by HAAF are assuming responsibility of liability for the client, and that I, as parent, guardian or client, assume full responsibility. I pledge full commitment to this program.