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Please note that all fields with a "*" are required
Identify the problem areas that you think the person you are concerned about has. Please check all that apply: |
1. Reading Of Words
Phonetic word attack (sounding out)
"Sight" word memory (remembering whole words)
Tracking words and lines
Distortions causing confused, laborious reading
Rhythmic Reading
Speed of Reading |
2. Reading Comprehension
Understanding What Is Being Read
Thinking about how it relates to other information
Remembering what has been read |
3. Spelling (Written and Oral)
Visual spelling (memorization of words)
Phonetic spelling (single and syllable sounds)
Symbol and sound [letter (s) and sounds] integration |
4. Attention Focus
Distractibility
Inattentiveness
Impulsivity
Over activity
Attention span
Concentration |
5. Directional Confusion
Reversals or confused sequence:
In reading
In writing
In math
Mis-speaks
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6. Listening Comprehension
Attending to spoken information
Understanding what has been heard
Thinking about what has been heard
Remembering what has been heard
Mis-speaking (malapropisms)
Speaking coherently and easily
Time relationships
Spatial(space) orientation
Map reading directions
Abstract/critical thinking
Concrete to abstract thinking
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7. Oral Expression
Formulating thoughts
Organizing thoughts |
8. Thinking Skills
Age appropriate awareness
Sequential Thought
Organized thought
Planning and goal orientation
Understanding and following directions |
9. Mathematics Reasoning
Understanding math concepts
Thinking about math concepts
Remembering math concepts
Understanding and remembering tables, charts, and graphs
Word problem mastery |
10. Mathematics Computation
Understanding basic and complex computations
(in all math areas from Addition through advanced Math)
Thinking about computation internally and externally
Remembering mathematic operations
Speed of computing |
11. Memory
"Executive" Function
(holding thoughts to store, think about/process)
Short-term memory
Long-term Memory |
12. Distractions or Distortions
"Irlen" syndrome
"Disorientation" (Davis) |
13. Writing
Handwriting legibility
Expressing oneself when writing
15. Other
Refinement of Receiving the Sounds (Phonemes)
Rhythmicity
Sequential Thought
Speed of Processing Sounds |
14. Study Skills
Sequencing and organizing
(to include planning, goal setting, and follow through)
Scheduling
Note Taking
Outlining
Reviewing
Memorizing |
So that we are better able to assist you, please provide us with some
background information on the person whose concerns you have identified above:
16. By filling out this form, what information do you hope to receive from the Kurtz Center?
Immediate Treatment options at the Kurtz Center
Future treatment options at the Kurtz Center
Information about the Kurtz Center's home based treatment programs
Other, please specify:
17. Are the areas of concern for a
A Child
An Adult
Person's Age:
18. Has the person been diagnosed with a learning disability?
Yes
No
If Yes:
When did you receive the diagnosis:
Who provided the diagnosis
What was the diagnosis?
19. Has the person received any prior treatment?
Yes
No
If so, please tell us where treatment was received (e.g. Public School, Private School, Private Business etc.) :
20. Please provide us with any additional information about your concerns.
I would like to receive your Newsletter.
Yes
No
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