5.
Please describe the Client's behaviors and issues.
6.
Please describe the areas that you would like to address with the REI Custom Program.
7.
Please list any medication the Client is taking.
8.
Please list any therapies the Client is undergoing.
1 out of 15
81.
Sees things others don't, such as shadows, colors, or objects moving.
83.
Feelings of hopelessness, helplessness, negativity.
84.
History of seizure activity that is currently inactive or controlled by medication.
85.
Fixates on a thought, activity or object.
86.
Confuses similar sounding words.
89.
Difficulty telling which direction a sound came from.
90.
Experiences uncontrollable vocalizations.
91.
Verbally abusive toward others.
92.
Difficulty understanding abstract ideas.
8 out of 15
95.
Trouble with time (always late, etc.).
96.
Engages in ritualistic behaviors; needs things a certain way all the time.
97.
Misinterprets others' comments; takes things the wrong way.
98.
Negative outlook on life.
99.
Abuses alcohol or drugs.
100.
Often has ringing in ears.
101.
Recoils from touch; tactically defensive.
102.
Makes the same mistakes repeatedly; doesn't seem to learn from mistakes.
103.
Doesn't seem to know where body is; bumps into things and people.
104.
Difficulty making decisions.
9 out of 15
105.
Thoughts of harming self (including suicide).
106.
Trouble grasping the 'big picture'.
107.
Argumentative; oppositional.
110.
Often tired, sluggish, slow moving.
111.
Repeated negative thoughts.
112.
Periods of confusion.
113.
Often lacks the ability to see options.
114.
Extreme cyclic changes in mood (very high to very low).
115.
Trouble making changes in action; gets locked into an action and can't change course.
116.
Frequently experiences deja vu (feelings of experiencing the same thing before).
10 out of 15
120.
Occasionally hears voices in head.
121.
History of head injury.
122.
History of brain damage.
123.
Often displays grandiose thinking.
124.
Trouble following through (on ideas, tasks, goals).
125.
Fearful of specific things (snakes, spiders, heights, people).
126.
Experiences frequent changes in sleep patterns.
127.
Thoughts of hurting others.
11 out of 15
129.
Lacks empathy; has trouble understanding others' feelings.
130.
Difficulty planning (tasks, activities, making goals).
131.
Thinks in terms of 'black and white'; trouble seeing nuances in situations.
132.
Difficulty understanding/identifying own feelings.
133.
Bothered by/sensitive to lights.
134.
Trouble with the law.
135.
Lies or exaggerates for no apparent reason.
136.
Has or had an eating disorder.
137.
Feels thoughts are fast; experiences many thoughts at same time.
138.
Adopted as a young child.
140.
Aggressive to others.
12 out of 15
141.
Trouble understanding verbal instructions.
142.
Non-verbal; doesn't talk.
143.
Lacks facial expressions.
144.
No interest in others.
145.
Unresponsive when spoken to.
146.
Regressed in language ability.
148.
Makes careless mistakes.
149.
Often tired in the morning.
150.
Often tired in the evening.
151.
Difficulty focusing; memory is poor.
152.
Sometimes falls asleep when doesn't want to.
13 out of 15
153.
Avoids going to noisy places such as restaurants, theaters, malls.
154.
Prefers music, videos or TV too loud.
155.
Often oblivious to certain sounds.
156.
Misunderstands often; asks “what” a lot.
157.
Difficulty judging how much to extend and flex muscles when dressing or during other activities.
158.
Uses too much force when handling objects; slams doors, spills cup, breaks objects, etc.
159.
Trouble judging the weight of an object; can’t tell the difference between two objects' weights.
160.
Prefers tight-fitting clothes.
161.
Seeks out highly physical activities involving bumping, jumping, or crashing into things.
162.
Loves wrestling and tackling.
163.
Responds negatively to light or unexpected touch.
164.
Highly sensitive to minor bumps, bruises, cuts.
14 out of 15
165.
Dislikes getting messy.
166.
Doesn’t like washing face, brushing hair, or brushing teeth.
167.
Unresponsive or under responsive when touched.
168.
Repeatedly touches surfaces or seeks rough textures to touch.
169.
Enjoys objects or activities with a strong sensory input.
170.
Unable to identify objects by touch, including shape, texture, temperature or size.
171.
Messy dresser; doesn’t care or seem to be aware of how clothes are hanging.
172.
Fearful of walking on stairs or uneven ground.
173.
Easily startled when unexpectedly moved or touched by someone.
174.
Craves intense, fast-moving activities.
175.
Enjoys spinning, swinging or bouncing and has difficulty stopping these activities.
176.
Has a limp body; slumps while sitting.
177.
Poor gross motor skills; difficulty catching, climbing, jumping.
178.
Easily fatigued; tires easily.
15 out of 15