INP Summary

Hope And A Future, Inc.

P.O. Box 13646 Ogden, UT 84412-3646 Phone: 801.395.1979 Fax:801.627.1831 Email: haaf@hope-future.org Website: hope-future.org
INDIVIDUALIZED NEURODEVELOPMENT PLAN SUMMARY
Today's Date:
Client Name:

First Name Last Name
Age:
Branch Evaluated:
Parent, Guardian, or Spouse Name:

First Name Last Name
Parent or Guardian Name:

First Name Last Name
Date of Last Evaluation:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number:

Area Code Phone Number
E-mail:
Please fill out in detail the areas that pertain to client's INP

Not everything will apply to your INP
1. List any changes to medications, supplements, dietary limitations, or health protocol currently using:
2. List any new health concerns, physical limitations, and/or seizure activity:
3. List current educational settings, extra curricular activities, and/or current therapies. Include number of days per week and time involved with each:
4. How consistent has the INP been implemented? List activities you have not been able to accomplish, as well as activities accomplished less than 50%.

5. Please make specific comments regarding success, changes, concerns, difficulties, and/or observations for the areas which apply:
a. Tactility (sensitivity to touch, pain, ticklishness, temperature, odors, taste, chewing, picky eating, drooling, comfort in writing, tying shoes, bedwetting, proprioception)
b. Auditory (Please note any comments/changes in auditory memory, following directions, listening to others, attention span, misunderstanding words, conceptualization, sensitivity to sound)
Digit Spans/Auditory sequences:
Consistently getting:
Working at:
Auditory Conceptual Words Sequence (ACWS):
Consistently getting:
Working at:
c. Visual Function (Please note any comments/changes in visual memory, visual attention/distraction, reversals, left/right confusion, eye convergence and tracking, eye contact, visualization)
Visual Digit spans/Object sequences:
Consistently getting:
Working at:
Visual Flash Digits:
Consistently Getting:
Working at:
Click to edit
d. Manual/Fine Motor Function (Please note any comments/changes is use of hands, pincer grasp, opening jars, doors, handedness, printing or cursive writing, pencil control and grasp)
e. Language (Please note comments/changes in vital capacity, articulation, pronunciation, ability to express thoughts, conversational skills, stuttering/stammering, mumbling, tongue use, lips, mouth open, mouth breathing)
f. Mobility/Gross Motor Function (Please note any comments/changes in crawling, creeping, walking, skipping, coordination, balance, tone, endurance, advanced skills)
g. Academic Function:
Math: Indicate book level and placement in book:
Visual Circle Math - Processes working on:
Math facts being retained?
What facts are known?
Skip counting be retained?
What multiples are known?
Note any comments/changes in computation skills, comprehension skills, word problems:
Reading: Indicate book level and placement in book:
High interest word cards: How many words does the client identify?
Please note any comments regarding the use of Highlighted or Experience Books:
Please note comments/changes in word decoding, fluency of reading, and comprehension:
Please note any other academic comments, concerns, or successes. List all curriculum, books, and software being used:

6. Behavior and emotionality (Please note any comments/changes in cooperation, over sensitivity, hurt feelings, overreactions, tantrums, rigidity, flexibility, moods, depression, attitude, obedience, frustration level, aggressive/destructive behavior, good/bad days, avoidance, tics, phobias). Please note discipline/management system being utilized:
BEHAVIOR - note on a scale of no concerns, mild, moderate or severe your level of concern:
Short attention span:
Difficulty following directions:
Hyperactive:
Difficulty with parents:
Hypoactive:
Difficulty with siblings:
Rigid or inflexible:
Difficulty with peers:
Impulsive:
Difficulty with teachers:
Explosive:
Few or no friends:
Anger (not explosive):
Socially immature:
Aggressive:
Perseveration (endless repetition):
Destructive:
Avoidance behavior:
Low frustration level:
Cyclical behavior:
Disorganized:
Cyclical achievement/academics:
Poor judge of time:
Phobias:
Emotional:
Tics:
Temper Tantrums:
Overly sensitive to pain:
Sucks thumb/fingers:
Overly sensitive to sound:
Bites nails/fingers:
Overly sensitive to odor:
Competitive:
Overly sensitive to taste:
Cooperative:
Overly sensitive to texture:
Follow through:
High pain tolerance:
Desire to withdraw:
Suicidal:

7. Social (Please note comments/changes in maturity, appropriateness of play/interaction with others, desire to communicate/interact with others, appropriateness of toy/imaginitive play)
8. Please list your questions and concerns:
9. How long does it take to complete 50% of your current INP?
10. How much available time and assistance do you have to go towards accomplishing the INP?
11. INP activities - Please list each INP activity, with specific comments regarding implementation of the activity and/or any changes you have noticed. Please be specific.
Should be Empty:

Hope And A Future, Inc.

INDIVIDUALIZED NEURODEVELOPMENT PLAN SUMMARY