Course Completion / Therapist #* The number received after completing the Listening with the Whole Body course
Client’s background* (Please provide brief history on past and/or present overall regulation, perception of space/time, motor skills, communication, attention, pertinent medical information, etc.)
Please provide the client’s listening history.* List CDs listened to in order of progression, length of time per CD, and client’s response to each CD.
How consistently has the Therapeutic Listening program been implemented?* Ex.: Client listens ______ minutes/ ______x/day. Name the times of the day client listens.
How has the client responded to the program?* Describe changes in emotional tone (i.e. more excited, more irritable, more animated, affect)
Arousal/Modulation (i.e. energy level, sleep/wake patterns, hunger/thirst, bowel/bladder, regulation, transitions, focus/attention, organization of self &
surrounding space)
Motor skill (i.e. activity participation, gross motor coordination, perception of space/time, timing/sequencing)
Social behavior (i.e. language, interaction with peers/family, awareness of self/self-esteem)
Respiration & Postural Control (i.e. breath patterns, movement patterns, fixation patterns, voice quality, presence of primitive reflexes)
Describe the client’s current sensory diet* (i.e. frequency, intensity, duration of specific Tx, types of activities included)
Any additional pertinent information:* (i.e. client medication changes, lifestyle changes—recent move to a new house/city/school, new sibling, etc.)
