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Format: Word Doc formats
Includes: 3 customizable forms + 1 red flag checklist
This professionally designed intake form bundle helps you gather the right information, right from the start. Instead of just focusing on visual acuity or refractive needs, these forms dig deeper into academic, behavioral, and functional red flags that often point to underlying visual challenges.
Whether you're evaluating a struggling student or looking for stronger communication tools with families and schools, this toolkit streamlines your case history process and equips you to spot when vision may be contributing to the problem.
What’s Inside:
Parent Academic & Behavior Questionnaire
Targets homework habits, attention, frustration, meltdowns, reading avoidance
Opens the door for deeper discussion about day-to-day struggles
Designed to flag possible visual contributors early
Teacher Classroom Concerns Checklist
Editable format to send to school or complete during the visit
Flags issues with copying, fluency, stamina, posture, and more
Builds rapport with educators and encourages referrals
Student Self-Report (Age-Adjusted)
Gives school-age children a voice in their own care
Screens for headaches, avoidance, tracking trouble, and visual discomfort
Simple, relatable language kids understand
Bonus: Red Flag Indicators for Referrals
A quick-reference clinical guide
Helps you know when to refer for vision therapy or multidisciplinary evaluation
Why It’s Valuable:
Efficiently screens for functional vision issues
Supports collaborative conversations with families and school
Improves case selection for vision therapy evaluations
Enhances the perceived professionalism and thoroughness of your intake process
Format: Word Doc formats
Includes: 3 customizable forms + 1 red flag checklist
This professionally designed intake form bundle helps you gather the right information, right from the start. Instead of just focusing on visual acuity or refractive needs, these forms dig deeper into academic, behavioral, and functional red flags that often point to underlying visual challenges.
Whether you're evaluating a struggling student or looking for stronger communication tools with families and schools, this toolkit streamlines your case history process and equips you to spot when vision may be contributing to the problem.
What’s Inside:
Parent Academic & Behavior Questionnaire
Targets homework habits, attention, frustration, meltdowns, reading avoidance
Opens the door for deeper discussion about day-to-day struggles
Designed to flag possible visual contributors early
Teacher Classroom Concerns Checklist
Editable format to send to school or complete during the visit
Flags issues with copying, fluency, stamina, posture, and more
Builds rapport with educators and encourages referrals
Student Self-Report (Age-Adjusted)
Gives school-age children a voice in their own care
Screens for headaches, avoidance, tracking trouble, and visual discomfort
Simple, relatable language kids understand
Bonus: Red Flag Indicators for Referrals
A quick-reference clinical guide
Helps you know when to refer for vision therapy or multidisciplinary evaluation
Why It’s Valuable:
Efficiently screens for functional vision issues
Supports collaborative conversations with families and school
Improves case selection for vision therapy evaluations
Enhances the perceived professionalism and thoroughness of your intake process