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.

• When you are ready to proceed with the evaluation, please fill in the following form.
• 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.
• When the evaluation is scheduled we will be glad to assess whether 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.
• 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*

Child's Name*

Child's Date of Birth

Age

M/FMaleFemale

Parent or Guardian Name

Address

City

State

Zip/Postal Code

Country (if not US)

Home Phone

Work Phone

Cell Phone

Email Address

How did you find us?

Diagnosis

Best Days and Times to Call

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?YesNo

Broken ear drum?YesNo

Age when brokenYesNo

Insertion of PE tubes?YesNo

Age when inserted

Date removed

Antibiotic use?YesNo

Allergies or food sensitivities?YesNo

To what?

Special Diet?

Medications and/or Nutritional Supplements? (Include dosages)

History of adverse reaction to immunizations?YesNo

If so, at what age, the specific immunization(s), and what was the reaction?

History of seizures?YesNo

If so what kind?

Brain or head injuries?YesNo

If so, at what age?

Difficulty with balance or coordination?YesNo

Difficulty with fine or gross motor skills?(handwriting, sports, etc.)YesNo

Pain threshold (high, normal limits, low)

Developmental History:

Were there any problems with the pregnancy/birth process?YesNo

Was there more than one ultrasound done during pregnancy?YesNo

Developmental milestones:

Age first crawled:

Walking:normal Limitsdelayed

Talking:normal Limitsdelayed

Toilet Training:normal Limitsdelayed

Other Milestones:

Speech/Language and Hearing Issues

(identify if current or in past):

Hearing impairment or loss?YesNo

Description

Sensitivity to loud sounds?YesNo

Choose one belowA few soundsSome soundsMany soundsMost sounds

Please indicate specific sounds if known

Hypersensitivity to quiet soundsYesNo
(i.e., hearing sounds others do not hear or before others hear them)?
Does the sensitivity to sounds vary?YesNo

If so, what causes it to do so?

Current or history of speech therapy?YesNo

What age?

Current language ability:Choose one belowNo WordsOne word2-3 wordsMost soundsnear sentencesfull sentences

Speech is:Easily UnderstoodDifficult for most people to understand

Stuttering or stammering problems?YesNo

Speech abnormalities or delays?YesNo

Difficulty with comprehension ?YesNo

Delayed comprehension?YesNo

Difficulty with sound discrimination?YesNo

Especially in noisy environments?YesNo

Difficulty concentrating/attending esp. in noisy environments?YesNo

Difficulty following directions or multi-step instructions?YesNo

Slow response time?YesNo

Psychological/Emotional or Neurological Issues

(identify if current or in past):

Depression?YesNo

Easily angered, irritable or impatient?YesNo

Anxiety/fears/phobias?YesNo

Attention deficit disorder?YesNo

ADD with hyperactivity?YesNo

Obsessions or compulsions?YesNo

Bipolar disorder?YesNo

Tic disorder / Tourette's syndrome?YesNo

Neurological issues? (Specify)

Other Disorders?

Social Issues

Discomfort or difficulty in social situations? (describe):

Inappropriate or immature social skills?YesNo

Difficulty maintaining relationships?YesNo

Is there any additional information you feel is important for us to know? Comments or concerns?

Enter Security Code :

Δ

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.