I personally answer every email I receive, and I do it promptly. This form makes our initial communication more efficient for both of us.
With proliferation of spam filtering strategies, many legitimate emails get filtered, including my response. This is happening more frequently. If I do not get back to you within a day, there is probably a technical problem, such as your email is bouncing. If you do not hear from me in a couple of days, please contact me by some other means, such as another email address. This is also why I am asking for an alternate email address or telephone number.
Please provide a thoughtful answer to each question.
Your First Name Your Last Name Your Role Mother Father Grandmother Grandfather Aunt Uncle Other Relative Self Friend
Patient's First Name Patient's Last Name Your Email Address
Alternate email address or telephone number
How old is your (grand) son/daughter/self?
Check ALL of the areas that you or professionals you have consulted with are concerned about.
ADHD/ADD , High Functioning Aspergers , PDD , Learning Disabilities , Home work struggles , Behavior Problems
Rather than Dr. diagnoses and testing, please describe what actual behaviors you are concerned about?
What medications are currently being used, with what effect?
If allowed, how long can he/she play computer games, GameBoy or watch TV, read and similar activities?
less than 10 minutes 10 to 30 minutes 30 min to an hour 1 to 2 hours greater than 2 hours
How have peers responded to his behavior? Does he/she have friends? How do they get along etc.?
How does his/her social behavior with adults compare with that with peers.?
How are his/her grades and behavior in school?
What is the configuration of your current family? Who lives in your home? If this is a blended family, what is the visitation schedule?
How would you evaluate your marriage? Very stable and happy Fairly good marriage Periodic conflict Emotionally distant relationship Unstable marriage Marriage may end
How do you think your spouse would evaluate your marriage? Very stable and happy Fairly good marriage Periodic conflict Emotionally distant relationship Unstable marriage Marriage may end
Why do you say this about the marriage?
Does anyone in your current family smoke? No Yes if yes, who?
Is anyone on psychotropic medications such as Zoloft, Prozac, Effexor, Concerta, Adderall, Ritalin etc. Who, and for what?
Does anyone have any health problems such as asthma, allergies, weight problems, depression, anxiety, phobias, headaches etc.
Any other information you think relevant?
I can respond more helpfully if I know how far along you are in learning about what I do. I have only read the WebSite I have read the first 6 chapters. I have ordered but not read your book. I have read your book
Thank you for taking the time to complete this form. .
I will review it promptly and email you my opinion on the utility of CAER treatment for this person.
Larry
Lawrence Weathers, Ph.D. Psychologist