4 Essential Skills
Who Can Be Helped?
What Can Be
and After Results
The Learning Connection
NEW TOLL FREE: (888) 556-0230
Please read the following carefully:
Mr. Shapiro is not a licensed
optometrist or opthalmologist. He does not diagnose or treat the
presence of abnormal conditions of the eye and its appendages, or the
accommodative and refractive conditions of the eye: or prescribe
visual training and/ or the use of scientific instruments to train the
visual system, and is not licensed in the state of Colorado to do
so. You should consult with and follow the instructions of an
optometrist or opthalmologist when using visual training procedures.
Part I - Preliminary Assessment Form
this form first, complete all information,
and fax completed form to (719) 495-7137
Name: __________________________ Grade: ____Age: ____
Parents Names: _________________________________
provide a brief history of your child's developmental and medical
history, citing any unusual difficulties, illnesses or experiences:
your child wear glasses? Yes
When was your child's last eye exam, either by the school or a
you know or suspect that your child has food, preservative or dye
sensitivities? Any other helpful information concerning food and/or
educational difficulties is your child experiencing?
describe your child's learning process and educational background
did you first notice school problems?
has been done for these difficulties?
you been pleased with the progress your child has made with these
programs? Please explain.
there other related problems, such as behavioral, social or
explain, briefly, the nature of these other problems:
does your child feel about his school performance?
your child's self-image low in regards to school achievement?
he motivated to do school work?
of Preliminary Assessment Form Part 1
Please continue to the SYMPTOM PROFILE
FORM: Part II: