Evaluation Report Form

Four weeks after you first begin program activities, please submit this form with four program tracking sheets. This form must also be submitted before each re-evaluation.

Today's Date: *

Month Day Year

Best Contact Phone Number: *

Area Code Phone Number

Evaluator's Name: *

Jan Bedell Other

Client's Name: *

First Name Last Name

Best Contact E-mail: *

Client's Age *

Client's Grade Level (if a student)

Client's Height *

Client's Weight *

Parent or Guardian's Name (if applicable): *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Has your address changed since your last evaluation?

Please list any medications or dietary supplements which the client is receiving. If there are none, please type n/a in the blank below: *

Please indicate any dietary limitations or if the client has specific dietary requirements. If there are none, type n/a in the blank below: *

Please indicate if there have been specific health problems that have occurred since the client's last evaluation. This would include seizures, infections, operations, broken bones, sleep issues, etc... *

Please indicate schools / classes being attended, extra curricular activities, therapies or the client's employment status. *

Please indicate the percentage of the total plan completed since the last evaluation: *

0% - 25% 26% - 50% 51% - 75% 76% - 100%

List any activities that have not been accomplished and why: *

Please make specific comments in each of the areas below, relative to the INP. Please include successes, changes, concerns, difficulties and / or any other observations.

Tactility- Please include comments about hypo / hyper sensitivity to touch, temperature or bath / shower and sensitivity to odors. Also indicate any specific food dislikes and whether it is due to taste or texture as well as if the client is irritated by tags and seams or if there are any bed wetting issues. *

Auditory Function- Please include any comments about the client's ability to follow directions, memory, attention span, hyper-sensitivity to sound, etc... *

Please indicate the client's auditory processing levels in the following areas (where applicable) at the time of previous testing:

Auditory Digit Span level at previous testing:

Auditory Numbers & Letters Mixed level at previous testing:

Auditory Conceptual Words (ACWS) level at previous testing:

Auditory Object Sequences (AOS) level at previous testing:

Please indicate the client's auditory processing levels in the following areas (where applicable) at the current level of testing:

Current Auditory Digit Span level: *

Current Auditory Numbers & Letters Mixed level:

Current Auditory Conceptual Words (ACWS) level:

Current Auditory Object Sequences (AOS) level:

If the client is receiving Samonas Sound Therapy please indicate the current CD, the number of times per day the client is listening and the number of minutes per day:

Visual Function- Make comments here on the client's visual function. This includes any letter and/or number reversals, eye convergence and tracking issues, eye contact, etc.. *

Please indicate the client's visual processing levels in the following areas (where applicable) at the time of previous testing:

Visual Digit Span (VDS) level at previous testing:

Visual Flash Digit (VFD) level at previous testing:

Visual Object Sequence level at previous testing:

Please indicate the client's visual processing levels in the following areas (where applicable) at the current level of testing:

Current Visual Digit Span (VDS) level:

Current Visual Flash Digit (VFD) level:

Current Visual Object Sequence level:

Manual / Fine Motor Function- Please include any comments regarding the client's manual or fine motor function. This includes opening jars, print or cursive writing, pencil grasp, typing, etc... *

Language- Describe the client's language abilities. Comments should include concerns or progress in relation to articulation (pronouncing word/sounds correctly), fluency, conversational skills, misinterpretation of spoken words, stuttering, mouth breathing, etc... *

Mobility/Gross Motor Function- Describe the client's abilities in regards to mobility/gross motor function. This area includes crawling, walking, coordination, balance, endurance, best time achieved for a one-mile run or three-mile walk, etc. *

Academic Function

Please complete the blanks for the applicable areas below. If not applicable, please leave the field blank.

Early Learning Foundations (Level and page number):

Visual Circle Math (Last step introduced) Include challenges or questions about how to proceed:

Math (book/curriculum being used along with level and page number):

Counting CD (track number):

Skip Count CD (track number or numbers mastered):

Rapid Recall - Which operation and what track number:

Keys to _____ (book) and page number:

Handwriting (book and page number):

"What Your ___ Grader Needs to Know (book and page number):

Word Flash computer game (level and track):

New Practice Reader (level and page number):

Reading About Science (level and page number):

Reading for Concepts (level and page number):

Pathways Reader (book and page):

Basic Reading Instruction (BRI) (level and book number):

Advance Reading Instruction (ARI) (level, book number and page number):

Detailed Reading Comprehension (101,201,301 - include sentence number); be specific about the progress when reading the sentence one time and filling in the answer sheet without looking back: