What To Do About Your Brain-Injured Child Course Online Questionnaire

Mother's First Name:

Mother's Last Name:

Father's First Name:

Father's Last Name:

Home Telephone Number:

Address Line1:

Address Line2:

City:

State:

Zip (Postal Code):

Country:

*E-mail Address: (required)

Please specify who checks this email address

Mother

Father

both Mother and Father

Other

Date of course you wish to attend:

Which parent(s) is/are enrolling in the course?

Mother

Father

both Mother and Father

Other

Mother's profession:

Father's profession:

Nature of child's problem:

How did you hear about the course?

What families do you know on The Institutes programs?

How did you learn about The Institutes?

We urge you to completely read the book What To Do About Your Brain-Injured Child by Glenn Doman

Mother, have you read What To Do About Your Brain Injured Child?

Yes

No

Father, have you read What To Do About Your Brain Injured Child?

Yes

No

Mother, if English is not your native language, please indicate your degree of fluency in English:

0%

25%

50%

75%

100%

Not Applicable

Mother's native language is:

Father, if English is not your native language, please indicate your degree of fluency in English:

0%

25%

50%

75%

100%

Not Applicable

Father's native language is:

INFORMATION ABOUT YOUR BRAIN-INJURED CHILD

Child's First Name:

Child's Last Name:

Child's Date of Birth:
(DD-MM-YYYY)

Age of child when the problem was first discovered (Example: 5 years or 2 months. Please don't just enter a number)

Degree of Visual Competence:

Description of Visual Competence of Child:

Degree of Auditory Competence:

Description of Auditory Competence of Child:

Degree of Tactile Competence:

Description of Tactile Competence of Child:

Degree of Mobility Competence:

Description of Mobility Competence of Child:

Degree of Language Competence:

Description of Language Competence of Child:

Degree of Manual Competence:

Description of Manual Competence of Child:

Does your child read?

Yes

No

Does your child have seizures?

Yes

No

Does your child take medicines or drugs?

Yes

No

What is your child's general state of health?

Please list all previous diagnoses:

Is your child currently attending school?

Yes

No

If your child is currently attending school, how many hours per day does he or she attend?

Image Validation

Please retype the image to the left in the box below:

STATEMENT OF GOALS AND OBJECTIVES

The What To Do About Your Brain-Injured Child Course is a course designed solely for parents. The objective of this one-week course is to teach the principles of Child Brain Development to parents so that those who wish to do so can design their own child development program at home. It does not qualify a parent to instruct other children, other parents, or professionals in the work of The Institutes for the Achievement of Human Potential. The goal of this course is to create better children, and therefore better adults, through parents.
We trust that parents attending this course will understand the importance of the objectives of this course and appreciate what it does, and does not, qualify them to do when they have completed it.
This course is designed to teach principles. It is not designed to teach or propose a specific program for any of the children whose parents attend. Indeed, The Institutes will not have ever seen, evaluated, or made a diagnosis for any of the children whose parents attend this course. For this reason the staff will not prescribe any program whatsoever. Nor can The Institutes take any responsibility for children who have never been seen here. It is absolutely vital that parents attending this course understand that they take full responsibility for their child's program and development, and, further, that The Institutes do not by implication or promise guarantee that the application of the program will cure a child. I have read and understood this STATEMENT OF GOALS AND OBJECTIVES of this course and agree that I am fully responsible for my child's program and development, and that attending does not qualify me to teach anyone but my own children. I agree to use this information only to teach my own children. I will not use the information from this course to teach other children, or to instruct other parents or professionals in the work of The Institutes. This commitment is critical to the understanding between The Institutes and me. Nothing in this STATEMENT OF GOALS AND OBJECTIVES grants any other license or rights in the work of The Institutes.

or

Copyright © The Institutes for the Achievement of Human Potential. All rights reserved. The Institutes for the Achievement of Human Potential, and The Institutes are registered trademarks of The Institutes for the Achievement of Human Potential and Registered in the U.S. Patent and Trademark Office.