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AIT Evaluation: Instructions and Form

Instructions
We look forward to working with you. If you are unable to come to our office for the evaluation,
we can work with the candidate at a distance. Long-distance care is available through our In-
Home Program which is individualized based upon a review of all of the following: (1) the
applicant's evaluation form; (2) telephone evaluation(s); and (3) a local audiologist’s report.

  1. When you are ready to proceed with the evaluation, please fill in the following form.
  2. To schedule the evaluation, call 828-683-6900 or email: info@aithelps.com. You can
    also go to our web site and submit a form request for an appointment. Do not hesitate to
    contact us with your questions.
  3. When the evaluation is scheduled we will be glad to assess whether insurance
    reimbursements, scholarship and/or payment plans are available to you. If you want us to
    do the additional financial assessment, please complete and submit the form entitled
    Scholarship, Payment Plans and/or Insurance.
  4. If the evaluation will be conducted at a distance, please schedule an appointment with a
    local audiologist for a hearing evaluation. We will send you a letter with instructions for
    the audiologist. Please instruct the audiologist to fax the results to us as soon as possible.
    If you have a child with special needs, we recommend that you find an audiologist who is
    trained to work with special needs children.

If AIT is appropriate, we can usually accommodate the In-Home Program fairly quickly.
You will need a CD player; we supply the rest of the equipment. The AIT is 20 sessions, 1/2 hour
each. The recommended program sequence is twice per day for 10 days. Re-assessments are
included.

Do not hesitate to call us for further information or assistance: 828-683-6900.

AIT PRE-SCREENING EVALUATION FORM - NEEDS ASSESSMENT

* - required fields, please
Date*
Name*
Date of Birth Age M/F
Parent or Guardian Name
Address
City & State Zip/Postal Code
Country (if not US)
Home Phone Work Phone
Email Address
How did you find us?
Diagnosis
Reason for inquiring about auditory integration training
 

Education: School and Grade
(current or highest level achieved)
Any academic problems in school?
Special classes? If so, please explain

Physical/Medical Issues

  
History of ear problems? Broken ear drum? Age when broken
Insertion of PE tubes?
Age when inserted Date removed

Antibiotic use? Allergies or food sensitivities?
To what?
Special Diet?
Medications and/or Nutritional Supplements? (Include dosages)
History of adverse reaction to immunizations?
If so, at what age, the specific immunization(s), and what was the reaction?
History of seizures? If so what kind?
Brain or head injuries? If so, at what age?
Difficulty with balance or coordination? Difficulty with fine or gross motor skills?
(handwriting, sports, etc.)
Pain threshold (high, normal limits, low)
 

Developmental History:

  
Were there any problems with the pregnancy/birth process?
Was there more than one ultrasound done during pregnancy?
Developmental milestones: Age first crawled:
Walking: normal Limits delayed
Talking: normal limits delayed
Toilet Training:normal limits delayed
Other Milestones:
 

Speech/Language and Hearing Issues
(identify if current or in past):
Hearing impairment or loss? Description
Sensitivity to loud sounds?
Please indicate specific sounds if known
Hypersensitivity to quiet sounds (i.e., hearing sounds others do not hear or before others hear them)?
Does the sensitivity to sounds vary?
If so, what causes it to do so?
Current or history of speech therapy? What age?
Current language ability:
Speech is Easily Understood Difficult for most people to understand
Stuttering or stammering problems? Speech abnormalities or delays?
Difficulty with comprehension? Delayed comprehension?
Difficulty with sound discrimination? Especially in noisy environments?
Difficulty concentrating/attending esp. in noisy environments? Difficulty following directions or multi-step instructions?
Slow response time?
 

Psychological/Emotional or Neurological Issues
(identify if current or in past):
Depression? Easily angered, irritable or impatient?
Anxiety/fears/phobias? Attention deficit disorder?
ADD with hyperactivity? Obsessions or compulsions?
Bipolar disorder? Tic disorder / Tourette's syndrome?
Neurological issues? (Specify)
Other Disorders?
 

Social Issues
Discomfort or difficulty
in social situations? (describe):
Inappropriate or immature social skills? Difficulty maintaining relationships?
 
Is there any additional information you feel is important for us to know? Comments or concerns?

Note: This form is strictly confidential. The completion of this form in no way obligates you or the practitionerto perform AIT. It is only to help us determine what is in the best interest of the applicant.

 

You are welcome to call us at (828) 683-6900.