INTERIM REPORT FOR KIDS

Name: ___________________________________________          Age: _______                Phase: _______

Completed by: ____________________________________           Date: _________________________

1.         During the last 30 hours, have you noticed changes in your child in any of the areas listed below?

Spelling                                     N/A      0          1          2          3          ___________________________________

Interesting reading                     N/A      0          1          2          3          ____________________________________

Reading aloud                           N/A      0          1          2          3          ____________________________________

Reading comprehension             N/A      0          1          2          3          ____________________________________

Ability to do math                       N/A      0          1          2          3          ____________________________________

Coordination                              N/A      0          1          2          3          ____________________________________

Balance                                    N/A      0          1          2          3          ____________________________________

Posture                                     N/A      0          1          2          3          ____________________________________

Body awareness                        N/A      0          1          2          3          ____________________________________

Sense of direction in space         N/A      0          1          2          3          ____________________________________

Judging spatial relantionship       N/A      0          1          2          3          ____________________________________
(i.e. puzzles, drawing)

Ability to do physical/                 N/A      0          1          2          3          ____________________________________
outdoor activities

Sense of rhythm                        N/A      0          1          2          3          ____________________________________

At ease with body                      N/A      0          1          2          3          ____________________________________
(i.e walking, running,
going downstairs)                       N/A      0          1          2          3          ____________________________________

Gross motor skills                      N/A      0          1          2          3          ____________________________________

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Bladder/bowel control                 N/A      0          1          2          3          ____________________________________

Fine motor skills                        N/A      0          1          2          3          ____________________________________

Maturity                                    N/A      0          1          2          3          ____________________________________

Flexibility                                  N/A      0          1          2          3          ____________________________________

Assertiveness                           N/A      0          1          2          3          ____________________________________

Appropriate responses                N/A      0          1          2          3          ____________________________________

Spontaneity                               N/A      0          1          2          3          ____________________________________

Interest/ curiosity in other           N/A      0          1          2          3          ____________________________________
people/ things   

Doing homework more               N/A      0          1          2          3          ____________________________________
independently

Motivation at school                   N/A      0          1          2          3          ____________________________________

Motivation in play                       N/A      0          1          2          3          ____________________________________
and social activities                  

Level of tolerance                      N/A      0          1          2          3          ____________________________________
(i.e. control of frustration,
Irritability)

Happiness/ well being                N/A      0          1          2          3          ____________________________________

Appropriate play                       N/A      0          1          2          3          ____________________________________

Desire to communicate              N/A      0          1          2          3          ____________________________________

Degree of interaction                  N/A      0          1          2          3          ____________________________________
with others

Expression of affection               N/A      0          1          2          3          ____________________________________

Degree of responsibility              N/A      0          1          2          3          ____________________________________

Needs instructions repeated       N/A      0          1          2          3          ____________________________________

Misinterprets questions              N/A      0          1          2          3          ____________________________________

Tendency to daydream               N/A      0          1          2          3          ____________________________________

Distracted by ambient                N/A      0          1          2          3          ____________________________________
sounds             

Sensitivity to sound                   N/A      0          1          2          3          ____________________________________

Sensitivity to touch
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 (i.e. tactile defensiveness)         N/A      0          1          2          3          ____________________________________

Fidgety behavior                        N/A      0          1          2          3          ____________________________________

Fear of hights/ falling                  N/A      0          1          2          3          ____________________________________

Where no danger exists              N/A      0          1          2          3          ____________________________________

Accident prone
(i.e. stumbling, tripping)              N/A      0          1          2          3          ____________________________________

Aggressiveness                         N/A      0          1          2          3          ____________________________________

Tantrums for no                         N/A      0          1          2          3          ____________________________________
apparent reason

Tendency to withdraw                N/A      0          1          2          3          ____________________________________

Moodiness                                N/A      0          1          2          3          ____________________________________

Degree of repetitive                    N/A      0          1          2          3          ____________________________________
behavior

2.         During the last 30 hours have you noticed that your child’s behavior has become worse in any areas listed above? 

Please describe.

_______________________________________________________________________________________________________________

3.         Do you have any other comments or observations, or are there any recent events in your child’s life which

may or may not be related to the program, that you would like us to be aware of?

______________________________________________________________________________________________________

Thank you for taking the time to complete this report.