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Can AIT PLUS Help Your Child

Fill in the questionnaire and email it to us. You may do so by pressing the SEND button at the foot of the form. We will let you know if your child is a suitable candidate for AIT PLUS.

Alternatively, you may print this form out, and post it to us at the address at the foot of the page.

Required fields on the form are shown - *

Your name: *
Street Address: *
Town: *
Country: *
Post Code *
Telephone No. *
Email address *
Child's name
Age
Diagnosis
Any difficulties during pregnancy ?
Was birth caesarean, induced, long labour or particularly difficult?
Cried a lot in infancy ?
Unusually good baby ?
Responded to early interactive play ?
Began to speak and regressed?
At what age were symptoms seen?
Slow development ?
Prone to ear infections ?
Several courses of antibiotics in childhood ?
Poor eye contact ?
Non verbal ?
Limited speech ?
Echolalia ?
Screams or laughs for no apparent reason ?
Unsociable/Withdrawn ?
Unusual or limited food preferences ?
Disturbed sleep patterns ?
Sensitive to some sounds ?
Dislikes being touched ?
Behaviour problems ?
Temper tantrums ?
Any allergies ?
Suffers from Asthma ?
Suffers from Epilepsy ?
Bed wetting after 5 yrs ?
Mood swings ?
Fidgety ?
Unusually anxious and fearful ?
Accident prone ?
Hyperactive ?
Aggressive ?
Poor co-ordination ?
Injures self or others ?
Does s/he use inappropriate movements such as rocking, whirling, hand flapping? Describe ...
Current medication if any ?
Has s/he been statemented ?
Any current program of remediation ?
What are your main concerns ?
Name and address of School
Name and address of GP
Has your child already been treated at the National Light & Sound Therapy Centre? If "Yes" give date...
Where did you first hear about the National Light & Sound Therapy Centre ?
Email the questionnaire today to find out if AIT PLUS could help your child


The National Light & Sound Therapy Centre
80 Queen Elizabeth's Walk, London N16 5UQ, England
telephone 0044 (0)208 880 1269 - or - fax 0044 (0)208 809 5420

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