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User Name: 
Intake Form - print version
Client Name
Home Phone
Cell Phone
Work Phone
Most Recent & or
Current School
Educational Level

Reason for referral to NoteWorthy Learning, a SOI ®-IPP ® Center:

How did you hear about NoteWorthy Learning?
Why have you contacted NoteWorthy Learning?
How would your life or your child's be different if the training we provide is successful?

Abilities Questionnaire:

How well do you perform the following tasks? You can answer "Really Well", "Okay", or "Not Well"

Coordinate small objects, visual objects, and sustain reading related activities that require visual focusing?
Understand, Organize, and Classify Materials, or Ideas?
Good eye-hand coordination when things need to be done fast?
Keep materials organized?
Concentrate on, recall, process numbers, visual details or written information?
Concentrate on, recall and change the sequence of information (numbers) you see?
Work and communicate with verbal ideas (vocabulary)?
Understand and communicate with abstract ideas and thinking?
Follow Directions the first time they are given?
Recall details in written material.
Remember and accurately apply information to the problem at hand. Take initiative?
Read, and scan data, items or words?
Use arithmetic facts from memory and perform tasks that require concentration.
Solve problems that require concentration, judgment and planning in data-dependent tasks?
Organize space and materials?
Concentrate on and recall information you hear?
Follow auditory instructions accurately the first time, hold them in your mind while working with them, and keep them in correct order?
Conceptualize and organize numerical data?
Understand spatial systems?
Understand objects and shapes in space from any perspective?
Discover and search out information when information on the job is abstract and ambiguous.
Use math concepts?
Make accurate decisions, using logic, good-judgment and planning to solve problems?
Creatively express spatial ideas.
Creatively apply semantic concepts?
Apply numerical concepts creatively.
Visually discriminate, use good eye hand coordination to work with and make decisions about detailed figural information.

Check & describe the concerns that apply to you or your child:

 Reading problems
 Problems with arithmetic or math
 Learning problems (general)
 Attention problems
 Head injury (stroke)
 Physical symptoms
 Career change
 Health Issues

Treatments Prior to NoteWorthy Learning:

 Special Education
 Vision Therapy
 AD/HD Medication
 Diet for Food Allergies
 Remedial Reading
 Speech Therapy
 Adaptive PE
 Sensory-Motor Integration Therapy


Do you have concerns about your vision?
Date of last visual exam
Have you been prescribed glasses for reading?
Do you wear them?

Additional Information:

Reading Strategy Questionnaire:

Think about what reading for information is like when you get to the point where you want to stop reading.  You can answer "Often," "Sometimes," "Never," or Don't Know "D.K."

Reading Difficulties
When you are reading for information and want to stop:
Do you accidentally skip lines or sentences?
Do you lose your place?
Do you misread words?
Do you unintentionally skip words or punctuation marks?
Do you read the same line over again?
Do you insert words from lines above or below?
Do you avoid reading or reading aloud?
Is your reading slow or choppy?
Are you bothered by white or shiny pages?
Do you look away, rest, or take breaks?
Are you restless, active, fidgety, or easily distracted?
Do you find that reading gets harder the longer you read?
Do you use your finger or marker?
Do you have a problem understanding what you read?
Do you have a problem remembering what you read?
Does it take effort to stay on the words you are reading?
What else happens when reading?
How often?
What else happens when reading?
How often?

Reading Discomfort
When you are reading for information and want to stop::
Do your eyes bother you?
Do they get red or watery?
Do they hurt, ache, or burn?
Do they feel dry, sandy, scratchy, or itchy?
Do you rub your eyes or around your eyes?
Do you feel tired, drowsy or fatigued?
Does your head bother you?
Do you get a headache?
Do you get dizzy?
Do you feel nauseated or sick to your stomach?
Do you open your eyes wide?
Do you squint or frown?
Do you find yourself blinking frequently?
Do you move closer to or further from the page?
Does it bother you to read under fluorescent lights?
Is it harder to read in bright lighting?
What else bothers you?
How often?
What else bothers you?
How often?

Reading History:

When answering these questions, think about what reading is like when you are reading for information and you get to the point you want to stop reading:

How do you, your head, and your eyes feel?
How does the page look when you want to stop reading?
What is your first symptom, (a) or (b)?
When do you first notice that this problem starts? - After you read

If you read a lot, do you ever:

Adapted from Irlen Short Intake Form
(Copyright©1998-2010 by Perceptual Development Corp/Helen Irlen. All rights reserved.)

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