New Intake, Start of Care

SOC Date:

Students Name:

Parent’s Names:

Address:                                                                                                  Email Address:

Phone:  Home:                                                                                        Cell:

Age/Birth date:                                                                                       Favorite Color:

Reading level:                                                                                         Grade/School                                         

Initial/SOC Learning Profile:  Gestalt (Right):                                       Logic (Left):

Dominant Eye:                                        Dominant Ear:                         Dominant Hand:     Dominant Foot:

F/u Profile:                                                                                              Left Handed family members?:  y/n

Heart Difficulties:                                                                                   Seizure History:

Concussions or Head Trauma:

History of Ear Infections:


Medication (Current and Past)

Nutrition:                                                                                                                Birth Trauma:

Sleep Patterns:                                                                                       Age Started School:

Smoker:   y/n   age started                                                                     Alcohol:  y/n   age started

History of Learning Difficulties on either side of the family?


Emotional Trauma:  Dangerous or frightening experiences:


Separation from main caregiver first 4 years of life?

Highly Sensitive Person?:  Score _____       Other Things I should Know about why you are here?:


Visual Integration

  1.  Did you crawl as a baby?
  2. Can you read in the car?  Any problems with car sickness?
  3. Do letters ever reverse?  b-d  p-b  other   How about numbers?
  4. Do words ever switch around?  Was—saw   on—no   it—the   other
  5. Do you have trouble spelling?  Short words? Easy words?
  6. Do you have difficulty with reading comprehension?
  7. Do you have trouble staying on the line when you read?  Do you skip words?
  8. Do your eyes ever water?   Headaches?   Neck aches?
  9. Do you wear glasses?  Do you have astigmatism?
  10. Does it bother you to work on school for a long time? Need a lot of breaks?
  11. Do the words ever wiggle?
  12. Do the words start to run together?   When?
  13. Do the words ever get fat or fuzzy, or develop a halo?
  14. Do you turn your head when you read?
  15. Do you tend to use one eye more than the other?
  16. Do you close one eye to focus?
  17. Do you find yourself skipping words when you read?
  18. Do you find that you skip lines when you read?
  19. Do you make pictures in your mind when you read?  Of what you imagine?




Auditory Integration

  1. Do you have trouble following directions which are given orally?  Do you need to have information or instructions repeated?
  2. Do you have difficulty remembering/following more than one or two directions?
  3. Do you have difficulty immediately recalling spoken information? (Silent Voice)
  4. Do you have difficulty remembering order or sequence of spoken information?
  5. Do you have difficulty recalling information after a time has passed?  (1 hr or more)
  6. Do you have difficulty remembering spelling words over time?
  7. Do you have difficulty remembering questions when called upon in class or meetings?
  8. Do you have trouble talking on the phone?
  9. Do you have difficulty understanding discussions, conversations?
  10. Do you have to see the person you are talking to in order to understand what they are saying?
  11. Do you have trouble alphabetizing things?
  12. Do you confuse similar sounding words?
  13. Do you have difficulty hearing different sounds?  (Phonetic awareness)
  14. Please write down the days of the week and months of year (see paper).
  15. Please repeat exactly what you hear me say (done on intake with me):

                A.  olives in vinegar                                B.  aluminum animal              C.  suddenly suspicious

                D.  curiosity seekers                E.  announced candidacy        F.  conscientious maneuver

Repeat the following sentences word for word after I say them:

  1.  Three men—raced down the hill—to the boat—in the river
  2. After dark one night—he gave the money—to his best friend
  3.  Do you hear your own voice speaking to you when you read silently?
  4. Do you have difficulty hearing and understanding in a quiet room?  (Silent Voice)
  5. Do you get confused in noisy situations?
  6. Are you easily confused?
  7. Do you have a problem with your temper?
  8. Can you do mental math?

Kinesthetic Integration — Hand/Eye Coordination

  1. Are all of your letters the same size, and can you stay on the line?
  2. Do your words ever run together when you write?
  3. Do you have poor posture when you write?
  4. Is your writing small or large?
  5. Do you print or write cursive?
  6. Do you have difficulty writing what you feel?
  7. Can you catch a ball? — Can you bat? — Can you throw the ball to someone else?
  8. Do you have good balance or coordination?
  9. Do you have a tendency toward clumsiness or awkwardness?
  10. Do you have to move around when you talk?
  11. Do you have confusion with right and left?
  12. Do you have good athletic skills?
  13. Can you line up your columns on math papers? 
  14. Please write the alphabet for me in lower case letters.  (See paper)
  15. Can you copy things from the board?
  16. Do copy work (see paper).

Posture:  good                                  bad

Writing:  LARGE                                 MEDIUM             SMALL

Letters:  same size                           On the line

Math Problems Lined up?             Yes                        No                         




Behavior and Social Skills

  1. Do you have a low frustration tolerance?
  2. How would you describe your self image or self-esteem?
  3. Do you withdraw from or avoid social interactions?
  4. Are you moody or do you have wild mood swings?
  5. Are you easily irritated?
  6. Do you get tense or anxious a lot?
  7. Do you have low motivation?
  8. Do you have trouble getting started?
  9. Do you have difficulty completing tasks?
  10. Do you have difficulty organizing yourself?
  11. Do you have difficulty planning your day?
  12. Do you tend to be forgetful?
  13. Do you have a problem with your temper?
  14. Are you excessively tired at the end of the day?
  15. Hyperactivity?
  16. Tendency toward depression?








Speech Difficulties

  1. Do you have difficulty with word retrieval?  (finding words he/she wants to say).
  2. Do you have difficulty speaking in complete sentences?
  3. Do you have difficulty organizing and expressing thoughts?
  4. Do you have difficulty telling a story in appropriate order?
  5. Are you afraid to speak in front of a group?
  6. Do you speak in mostly phrases or single sentences?
  7. Can you give detailed information?
  8. Do you have difficulty stuttering?
  9. Do you have difficulty saying certain sounds?
  10. Do you have difficulty completing open-ended questions?
  11. Do you lose your way in sentences or fail to finish longer sentences?
  12. Do you frequently mispronounce words?











Three Goals for the student

DATE:  ______________________________

Student Name:  _______________________

  1. Goal One:



  1. Goal Two:



  1. Goal Three:



  1. Other things I want you to know:



  1. Tips Teachers and Parents









Name:  _________________________________  Grade:  ______  Date:  _______



  1.  Write the days of the week:



  1. Write Numbers One through Ten:



  1. Write the Alphabet in lower case letters:



  1. Write the Months of the Year:



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