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 document.

You must hit the save for it to save.

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

IMPORTANT NOTE:

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

You must hit the save for it to save.

IMPORTANT NOTE:

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

You must hit the save for it to save.

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 as soon as it is finished. Please email it to office@BrainSprints.com or fax it to 972.325.4119.

IMPORTANT NOTE:

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

You must hit the save for it to save.

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:

Please indicate if the client enjoys the following activities and the amount of time spent on each activity daily:

The Neuro-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 PC-Advanced system. 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.

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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 for In-Person Evaluations

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.

Payment Options: Please Read Carefully

A) Pay for the first year with Brain Sprints PC-Advanced in full. $2175.50 processed on the day of submission.

B) Pay for the first year with Brain Sprints PC-Advanced in monthly payments.
$525 deposit processed on the day of submission. Monthly payments will begin the following month on the 1st or 15th (select below) and will be $235 for 8 months.

If you are paying monthly and decide to withdraw from the PC-Advanced 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.**

I give Brain Sprints permission to charge either A) one time payment of $2175.50 or B) deposit of $525 and based on my option chosen above, payments of $235.00 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-Advanced 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.