Cerebral Matters, LLC

REGISTRATION FORM - WINTER/SPRING TRAINING PROGRAMS - 2010

Please check the program(s) of your choice:

HIGH SCHOOL MASTERY

MIDDLE SCHOOL MASTERY

Grades:

High School Students

Grades:

Middle School Students

Dates:

Tuesdays starting January 19
10 Sessions/Weeks

Dates:

Wednesdays starting January 20
10 Sessions/Weeks

Time:

4:30 - 6:30 pm

Time:

4:30 - 6:30 pm

TRAINING THE CEO OF THE BRAIN

Grades:

Elementary School Students

Dates:

Thursdays starting January 21
10 Sessions/Weeks

Time:

4:30 - 6:30 pm

Fee for each training program is $ 2,100 for 10- weeks.
The pre-registration fee of $500 per program is non-refundable, and must accompany the registration form in order to ensure your spot, since each program has limited admittance. The balance is due on the first day of the program. Total number of participants per program is a maximum of 5 children.

PROGRAM DETAILS
Please arrive 10 minutes before the program starts. Each program will begin and end on time.Each student will be provided additional work to be completed at home. Parents can assist this process with regular follow-ups.

REGISTRATION PAYMENT(S) MUST ACCOMPANY THIS FORM
Please mail your check payable to Cerebral Matters for the
Pre-Registration Fee of $500 per program and completed registration form to:

Attention: Sucheta Kamath
Winter/Spring Programs 2010
Cerebral Matters
6100 Lake Forrest Dr., Suite 108
Atlanta, GA 30328

You can also contact me at 404-493-0962 or by fax at 404-257-9768.

PRE-REGISTRATION IS NECESSARY and is on a first come first serve basis.

For confirmation you may call 404-493-0962 or email sucheta@cerebralmatters.com. You will receive a receipt as well as a letter of confirmation within 1 week of receiving the registration form and the pre-registration fee. Fee is refundable, less $50 administrative fee, until January 15. After January 15, 2010 the fee is non-refundable.

HISTORY AND BACKGROUND INFORMATION

CHILD'S NAME:

AGE:

ADDRESS:

BIRTHDATE:

CITY:

SIBLINGS:

STATE:

CHILD'S EMAIL:

ZIP CODE:

CHILD'S CELL #

HOME PHONE:

FATHER'S NAME:

WORK#

FATHER'S EMAIL:

MOBILE#

MOTHER'S NAME:

WORK#

MOTHER'S EMAIL:

MOBILE#

CURRENT GRADE:

SCHOOL:

PEDIATRICIAN:

OFFICE#

DIAGNOSIS, IF ANY:

EVER EVALUATED BY A PSYCHOLOGIST? YES NO

IF SO, DATE OF MOST RECENT EVALUATION:

DONE BY:

(Please provide a copy of this report if possible.)

EVER EVALUATED BY A SPEECH-PATHOLOGIST? YES NO

IF SO, DATE OF MOST RECENT EVALUATION:

DONE BY:

(Please provide a copy of this report if possible.)

REASONS FOR ENROLLING YOUR CHILD IN THIS TRAINING PROGRAM (Please list top 10 concerns):

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

BIRTH HISTORY

ADOPTED?

YES NO

IF YES, WHAT AGE?

FULL TERM?

YES NO

IF NO, GESTATION?

PARANATAL COMPLICATIONS?

YES NO

IF YES, DESCRIBE:

DELIVERY COMPLICATIONS?

YES NO

IF YES, DESCRIBE:

NORMAL DELIVERY?

YES NO

CAESARIAN SECTION?

YES NO

IF ANY EXTENDED HOSPITAL STAY NECESSARY AS A BABY,
PLEASE LIST ANY DIAGNOSTICS AND MEDICAL TREATMENTS GIVEN:

MEDICAL / NEUROLOGICAL HISTORY


Please check any diagnosis that have been confirmed, treated, or are currently in question:
	DYSLEXIA	NONVERBAL LEARNING DISABILITY
	ATTENTION DEFICIT DISORDER	OBSESSIVE-COMPULSIVE DISORDER
	ASPERGER'S SYNDROME	AUTISM / PDD
	CENTRAL AUDITORY PROCESSING DISORDER	SENSORY INTEGRATION IMPAIRMENT
	LANGUAGE BASED LEARNING DISABILITY	LANGUAGE DELAY
	HEAD TRAUMA OR WHIPLASH INJURY	HEARING IMPAIRMENT
	DEPRESSION	EAR INFECTION
	OTHER, PLEASE SPECIFY:

CURRENT MEDICATIONS
NONE
	NAME	INDICATIONS FOR USE	DOSAGE	START DATE






	COMMENTS:

HISTORY OF TREATMENT FOR THIS PROBLEM

SERVICE PROVIDER	DURATION	COMMENTS

EDUCATIONAL HISTORY:

FAMILY HISTORY / OTHER PERTINENT HISTORY:

DESCRIBE ABILITY TO MAKE FRIENDS, INTERACT WITH PEERS, TEACHERS AND ADULTS:

DESCRIBE YOUR WINTER/SPRING (WHAT WILL THE CHILD BE DOING DURING THE WINTER/SPRING AND DO YOU ALLOCATE ANY TIME FOR SKILL BUILDING PROCESS DURING THIS TIME)?

SCHOOL PERFORMANCE (Describe your child's MOST RECENT academic performance):

SUBJECT	GRADE	TEACHER'S COMMENTS

DESCRIBE HOW YOUR CHILD USES AN AGENDA OR DAILY PLANNER (Does your child have one or not, if so, how is it used)?

DESCRIBE YOUR CHILD'S ACADEMIC PARTICIPATION:

DECRIBE HOW YOUR CHILD USES SUBJECT BINDERS: (Does your child have one or not, if so, how is it used)?

DESCRIBE HOW YOUR CHILD COMPLETES HIS/HER HOMEWORK:

DESCRIBE HOW YOUR CHILD STUDDIES FOR A TEST:

DESCRIBE HOW YOUR CHILD COMPLETES A PROJECT ASSIGNED BY TEACHERS:

NOTE: Please feel free to attach samples of your child's work or additional information to aid us in helping your child.

PLEASE PROVIDE ANY ADDITIONAL COMMENTS:

HOW DID YOU HEAR ABOUT OUR PROGRAM?

WOULD YOU LIKE MORE INFORMATION ABOUT PARENTING WORKSHOPS
OR TREATMENT OPTIONS OFFERED DURING THE YEAR? YES NO

Please PRINT this form, include a check payable to Cerebral Matters for the
Pre-Registration Fee of $500 per program, and MAIL to:

Attention: Sucheta Kamath
Winter/Spring Programs 2010
Cerebral Matters
6100 Lake Forrest Dr., Suite 108
Atlanta, GA 30328

After PRINTING the form, please submit the information to Cerebral Matters via email.