Client Application and History Form

  • PC-Elite History and Application Form

  • IMPORTANT NOTE:

    Please gather any documentation from previous medical and educational testing before beginning the application process. This form will take approximately 60 minutes to complete. We have added a save button at the bottom of the page.  You must hit the save for it to save. 

    You will be emailed a copy of this document for your records after submission.

  • Date:*
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  • Client Information

  • Client's Sex:*
  • Client's Date of Birth*
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  • Client's Educational / Employment Status: (Please check all that apply):*

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  • Client lives with:*

  • Family Information

  • Is client adopted?*
  • Father's Date of Birth
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  • Mother's Date of Birth
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  • Medical History (Birth to Present)

  • Was the client delivered via C-Section?
  • Has the client ever received a head injury?*
  • Has the client ever broken any limbs?*
  • If yes, indicate which limb(s):
  • Does the client have headaches?*
  • Has the client had any surgeries?*
  • Is the client currently seeing a specialist? Please check all that apply:

  • Has the client ever taken a three mile hike?*
  • Has the client ever run a mile without stopping?*
  • Does the client sleep with his / her mouth open?*
  • Does the client snore? *

  • Visual Information

  • IMPORTANT NOTE:

    We have added a save button at the bottom of the page. 

    You must hit the save for it to save.  Hit Save!

  • Please check any conditions below the client has been diagnosed with:

  • Has the client had a recent eye exam?*

  • Does the client see 20/20?
  • Please check areas of visual concerns in regards to writing:

  • Check all areas of visual concerns in regards to reading:

  • Has the client ever received vision therapy?*
  • Does the client have poor eye contact?

  • Auditory Information

  • Does the client have a history of colds or sinus congestion?*
  • Does the client have a history of ear infections?*
  • Has the client suffered any hearing loss?*
  • Does the client experience tinnitus (perception of noise or ringing in the ears)?*
  • Is the client overly sensitive to sounds?*
  • Does the client experience tonal processing issues or often misinterpret words spoken?
  • Has the client received any of the following? Check all that apply.*
  • Does the client experience physical tics?
  • Does the client experience fears?
  • Does the client experience phobias?
  • Does the client listen to music?
  • Please check any areas of concern below:

  • IMPORTANT NOTE:

    We have added a save button at the bottom of the page. 

    You must hit the save for it to save.  Hit Save!

  • Dietary

  • Use the link provided here to access your 7-day food diary. Please fill it out as completely as possible. You may return this document on your appointment day, email it to office@BrainSprints.com, or fax it to 972.325.4119 before your appointment.

  • Was the client nursed?
  • Rows
  • Rows
  • Please check any concerns in the following areas:

  • Developmental

  • Please indicate the age in months and years when the following developmental steps were achieved as well as any comments about that stage of development:

  • Indicate if the client enjoys the following activities and the AMOUNT OF TIME SPENT on each activity daily:

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  • Language

  • IMPORTANT NOTE:

    We have added a save button at the bottom of the page. 

    You must hit the save for it to save.  Hit Save!

  • Put a check in the box if there are any concerns in the following areas:

  • Does the client use sign language:
  • Is the client able to say a sentence in another language:

  • Manual

  • Check the box where there may be a concern:
  • Is the client able to type?
  • If yes, does the client know the home row keys?
  • Does the client print with both upper and lower case letters?
  • Does the client write in cursive?
  • Rows
  • Have you ever thought that this person should really be using the opposite hand?*
  • Did it take long for the client to choose a dominant hand?
  • Was the client encouraged to use one hand over another at an early age (before 7 years old)?*
  • Does the client have an identical twin?
  • Are any of the following people (who are biologically related to the client) either left handed or considered to be ambidextrous?*

  • Academics

  • Are there are concerns in these areas (check all that apply):
  • Rows

  • Behavior

  • Rows
  • Does the client have any emotional or behavioral difficulties?
  • Is there a family history of emotional or behavioral disorders?

  • IMPORTANT NOTE:

    We have added a save button at the bottom of the page. 

    You must hit the save for it to save.  Hit Save!

  • Overall Goals and Plan

  • The Nuero-Developmental Approach is not a "quick fix". It takes time and dedication to build new neural pathways in the brain. It is a gradual process; changes will occur, but over a period of several months. It always amazes us how quickly our clients forget the struggles they have been dealing with for so long. They begin working the program and positive changes begin to occur and they quickly adapt to the new circumstances and forget that, prior to their work on the INP (Individualized NeuroDevelopmental Program), their child would only eat peanut butter and jelly sandwiches, or couldn’t sit still for five minutes, or couldn’t read or write, or screamed anytime they were touched, or never made eye contact, etc.

    This part of the History Form and Application document is for our future use; to remind you, if needed, what your goals are and what you are hoping to accomplish with the Brain Sprints program. Some of our clients become weary after working the program for one year and they begin to lose sight of their original goals and they don’t remember how far they/their child has come because they are too close to the situation and because we humans adapt so quickly to new circumstances. If this should happen to you, we will use the information below to encourage you, motivate you and inspire you to keep on keeping on!!!

  • Brain Sprints is a Christian educational organization. Brain Sprints utilizes an eclectic approach to eliminating learning, motor and speech inefficiencies. The developmental and educational plans are individualized for each client. Activities recommended are not medical, therapeutic, or psychological prescriptions. Activities are offered for the client and families’ review, investigation and education. Application of activities is the responsibility of the client and/or family. Brain Sprints Nuero-Educational Specialists are educators and 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 Brain Sprints or those trained by or employed by Brain Sprints are not assuming responsibility or liability for the client, and that I, as parent, guardian or client, assume full responsibility.

  • IMPORTANT NOTE:

     Hit Save!

  • New Client Orientation and Commitment Letter


    Brain Sprints has a unique approach to building leaders and addressing learning difficulties and disabilities. The techniques used on the Individualized NeuroDevelopmental Programs (INP) are tried and true, having received proven results with thousands of adults and children across the country for more than 30 years. The successful elimination of neurological inefficiencies has only been present where the INP has been implemented with consistency over a long enough period of time. To accomplish your goals as an individual or new parent on our program, we ask you to review this mutual commitment agreement.


    My commitment to you as your evaluator:
    ✓ Perform the most comprehensive evaluations possible.
    ✓ Supply you with up-to-date activities to address the challenges your child is experiencing.
    ✓ Make support available by phone, bi-monthly zoom meetings and e-mail to discuss any concerns or challenges you may be experiencing in implementing the INP.

    Please read the following carefully, check the boxes and sign at the bottom.

  • Cancellation Policy

    Please be aware that we often have families waiting for an available appointment.

    We appreciate your consideration in giving us as much notice as possible if you cannot be at your scheduled appointment.

    Emergencies and Illness
    We realize that at times cancellations due to family emergencies or illness is unavoidable. Thank you in advance for not bringing a sick child (fever within the last 24 hours) to an evaluation.
     
    We will work with you to reschedule your appointment for the next available appointment time as soon as possible.  Please be aware that due to our limited schedule in certain locations, this appointment may not be available in your geographical area so travel maybe involved.

  • My signature indicates that I have read and understand all the policies. 

  • PC-Elite Payment Agreement

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  • Payment Options: Please Read Carefully

    A) Pay for the first year with Brain Sprints PC-Elite in full.
    $500.00 deposit processed on the day of submission and $2,578 to be processed immediately following your evaluation.

    B) Pay for the first year with Brain Sprints PC-Elite in monthly payments.
    $500 deposit processed on the day of submission, $500 processed immediately following your evaluation. Monthly payments will begin the following month on the 1st or 15th (select below) and will be $295 for 8 months.

    If you are paying monthly and decide to withdraw from the PC-Elite system, to stop payment you must contact office@brainsprints.com seven business days (Mon-Fri) prior to the date of your next monthly payment.

    **These options assume a year commitment and are non-refundable. Monthly payments are non-refundable once processed.**

  • Payment Choice*
  • Process my payment on the:*
  • We have an immediate family member currently doing Brain Sprints.

  • I give Brain Sprints permission to charge my deposit of $500 and based on my option chosen above: A) one time payment of $2578 or B) payments of $295.00 on a monthly basis for 8 months.  Your signature at the bottom of this page means you agree to let Brain Sprints process payments on the provided credit or debit card on the next page. I understand that there is no refund for amounts paid. I understand that I will need to provide seven business days notice prior to my next payment when I would like to discontinue the PC-Elite system.

    I certify that I am an authorized user of the credit/debit card provided and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.

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