EmailMe Form - Neurohealth Brain Training Center

FIRST Name ONLY *

Client Number *

Today's Date *

MM / DD / YYYY

Number of days since last session *

Person filling out report *

Please select all that apply
COGNITIVE

EMOTIONAL REGULATION

Anxiety

Lack of Joy/ Blah Mood

Overreactivity

Self-Esteem

BEHAVIOR REGULATION

Impulsivity

Motor Overarousal/ Hyperactivity

Oppositional-Resistant

Social-Interpersonal

OTHER

Chronic Pain

Sleep

Other

Is anxiety at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
feels more relaxed and more "at ease" *

Feels less overwhelmed/ is coping better *

Has less worrying or fearful reactions *

Anxiety Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is drive/motivation/self-starting at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
feels more like doing things *

Has less procrastination or avoidance of tasks that need to get done (homework, chores, etc.) *

Can maintain action toward a non-preferred task for longer periods of time *

Drive/ Motivation/ Self-Starting Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is attention/distractibility at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
requires less repetition of instructions *

Has less distractibility and/or requires less re-directioning to stay on task *

Can stay with a task longer before "running out of gas" or "getting off track" *

Attention/ Distractibility Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is executive functioning/organization at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
is less forgetful about tasks that need to be completed *

Is less disorganized with materials (books, papers, etc.) *

Is less scattered/ unsure of where to start on a task *

Executive Functioning/ Organization Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is memory/information processing at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
"picking up" on concepts better than usual *

Is better able to comprehend what was said by others and/or what was read *

Requires less repetition of information in order for it to make sense and/or be remembered *

Memory/ Information Processing Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is impulsivity at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week..
is less likely to make careless errors; less rushing through work *

Is able to wait his/her turn somewhat more than is typical *

Is less prone to interrupting others in conversation; less "blurting" out *

Impulsivity Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is inflexibility at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
can "go with the flow" more easily *

Has fewer bothersome/ unwanted or repetitive thoughts *

Less need to have things "just right" or a "certain way" *

Inflexibility Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is self-esteem at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
has less "harsh" thinking toward self *

Confidence "on the rise;" less self-doubt *

Self-Esteem Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is lack of joy/blah mood at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
is less down/sad; "blah" mood *

Is able to experience things as more pleasurable/ less dreadful *

Has less dark or self-defeating/ negative thinking *

Has fewer repetitive thoughts about bothersome thought content *

Lack of Joy/ Blah Mood Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is overreactivity at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
overreacts less frequently than is typical *

Is less grumpy, irritable, or bothered by things *

Recovers faster after getting upset *

Overreactivity Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is sleep at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
seems less tired in the morning *

Is able to wake up more easily *

Is able to fall asleep faster *

Is able to sleep with fewer awakenings *

Sleep Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is chronic pain at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
has less intense or less frequent pain *

Has fewer "bad days" associated with pain *

Chronic Pain Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is sensory processing/sensitivity at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
is less sensitive to sound, light, or touch *

Seems less overwhelmed/ distracted by their environment *

Sensory Processing/ Sensitivity Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is social-interpersonal behavior at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
is doing fewer socially inappropriate things; less awkward or fewer social "mistakes" *

Has an increased desire to connect/ interact with others; less social anxiety/ avoidance *

Seems less in his/her "own world" or is more "present" *

Social-Interpersonal Behavior Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is oppositional/resistant behavior at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
has less disrespectful behavior *

Is more cooperative than is typical *

Is generally less "difficult" or stubborn *

Oppositional-Resistant Behavior Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

Is motor overarousal/hyperactivity at least SOMEWHAT better than initial baseline? *

True

Somewhat True

False

Over the past week...
is able to sit longer in situations where he/she is "restricted" (at a restaurant, etc.) or when focusing on a task *

Has fewer signs of fidgeting and feels more settled physically *

Motor Overarousal/ Hyperactivity Rating *

9-10- Severe
7-8- Very Difficult
5-6- Problematic, But Not Severe
3-4- Problem Present, But Manageable
1-2- Mostly Absent
0- Absent

"Other" Symptom Rating

Please explain your ratings on the above symptoms *

Other comments or concerns

Have there been any environmental factors or events that may be influencing these symptom ratings?
(ie: medication changes, social conflicts, increased stress, cold/fever, etc.) *

If you answered "YES" to the above question, please explain below

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