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  1. The following statements describe auditory processing and language based concerns that some children may have. Please indicate the behaviors which are considered to be a concern to you.
  2. Full Name (*)
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  3. E-mail (*)
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  4. Phone
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  5. Appears “fidgety” or “restless” across different situations.
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  6. Has troubles focusing or paying attention during tasks or play.
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  7. Is easily distracted by things going on around them.
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  8. Daydreams or appears to be “staring into space” when he/should be paying attention.
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  9. Difficulties in school both academically and with peer relationships.
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  10. Disturbs other children.
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  11. Difficulties finishing things and following through with instructions.
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  12. Gets caught up in the details and misses the “big picture.”
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  13. Becomes easily frustrated during efforts to complete projects.
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  14. Often blurts out or does not wait his/her turn to speak.
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