Main Page The KURTZ CENTER DIVISION OF TCLC Home Treatment Summer Programs Workshops - Brain Training! Welcome to Our Site Areas of Treatment Our List of Programs Case Studies & Results Testimonials Contact Us Our Location Join Our Team Diagnostics for PACE Treat Cause, Not Symptoms FCAT Prep Courses! Successful Treatment Articles & News of  Interest Other TOP OF PAGE Instructor Development Kurtz Groups	Identify the problem areas that you think the person you are concerned about has. Please check all that apply:
	Please note that all fields with a "*" are required *Name:  *Address: *City:   Telephone: *State:  *Zip Code:  *Email:
	1. Reading Of Words Phonetic word attack (sounding out)  "Sight" word memory (remembering whole words) Tracking words and lines  Distortions causing confused, laborious reading Rhythmic Reading  Speed of Reading
2. Reading Comprehension Understanding What Is Being Read  Thinking about how it relates to other information  Remembering what has been read	3. Spelling (Written and Oral) Visual spelling (memorization of words)  Phonetic spelling (single and syllable sounds) Symbol and sound [letter (s) and sounds] integration
4. Attention Focus Distractibility  Inattentiveness  Impulsivity  Over activity Attention span  Concentration	5. Directional Confusion Reversals or confused sequence: In reading  In writing  In math Mis-speaks
6. Listening Comprehension Attending to spoken information  Understanding what has been heard Thinking about what has been heard  Remembering what has been heard	7. Oral Expression Formulating thoughts  Organizing thoughts  Mis-speaking (malapropisms) Speaking coherently and easily
8. Thinking Skills
Age appropriate awareness  Sequential Thought  Organized thought Planning and goal orientation  Understanding and following directions	Time relationships  Spatial(space) orientation  Map reading directions Abstract/critical thinking  Concrete to abstract thinking
9. Mathematics Reasoning Understanding math concepts  Thinking about math concepts Remembering math concepts  Understanding and remembering tables, charts, and graphs Word problem mastery	10. Mathematics Computation Understanding basic and complex computations (in all math areas from Addition through advanced Math) Thinking about computation internally and externally Remembering mathematic operations  Speed of computing
11. Memory "Executive" Function (holding thoughts to store, think about/process) Short-term memory  Long-term Memory	12. Distractions or Distortions "Irlen" syndrome  "Disorientation" (Davis)
13. Writing Handwriting legibility  Expressing oneself when writing 15. Other Refinement of Receiving the Sounds (Phonemes) Rhythmicity Sequential Thought Speed of Processing Sounds	14. Study Skills Sequencing and organizing (to include planning, goal setting, and follow through) Scheduling  Note Taking  Outlining  Reviewing  Memorizing

So that we are better able to assist you, please provide us with some 
background information on the person whose concerns you have identified above:

16. By filling out this form, what information do you hope to receive from the Kurtz Center?
Immediate Treatment options at the Kurtz Center
Future treatment options at the Kurtz Center
Information about the Kurtz Center's home based treatment programs
Other, please specify:

17. Are the areas of concern for a  A Child  An Adult
Person's Age:

18. Has the person been diagnosed with a learning disability?  Yes  No 
If Yes:
When did you receive the diagnosis:
Who provided the diagnosis
What was the diagnosis?

19. Has the person received any prior treatment?  Yes  No
If so, please tell us where treatment was received (e.g. Public School, Private School, Private Business etc.) :

20. Please provide us with any additional information about your concerns.

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