Dates of AIT Session Requested

Session Location Requested

Time preference - Please indicate first choice of daily sessions. (both times indicated per line)
These are estimated times that the sessions will be scheduled, specific times will be verified one to two weeks before the start of the AIT session and may be 15 to 30 minutes earlier or later than the estimated times on this schedule.

9:00 - 9:30 AM AND 1:00 - 1:30 PM

9:45 - 10:15 AM AND 1:45 - 2:15 PM

10:15 - 10:45 AM AND 2:15 - 2:45 PM

11:00 - 11:30 AM AND 3:00 - 3:30 PM

11:30 AM - 12:00 PM AND 3:30 - 4:00 PM

12:00 - 12:30 PM AND 4:15 - 4:45 PM

Participant's Name

Date of Birth

Parent/Guardian Name(s)

Address ZIP

Phone E-mail

Referred by

Participant's Diagnosis

Date of Diagnosis

Noted sound sensitivities & other sensory difficulties

Current education placement and/or level of functioning

Current medications

Other interventions

Seizures?    Ear Tubes?    Ear Infections?

Is your child verbal?

If not, what form of communication is being used?

At this time, is your child comfortable wearing headphones?

Sleep challenges?

Behavior challenges?

Participant's strengths and weaknesses

Has your child had a recent hearing test?

When?

Is there any other pertinent information that you would like to share with us

regarding your child?

Do you require financial assistance. If so, describe your circumstances.