Educational Support with Ms. Marjorie

A Wholistic Approach to Strengthen the Foundations of Behavior and Learning

Please use these enrollment forms to fill out and submit online. Thank you for taking the time to answer these questions thoughtfully. Your input is essential to helping me get to know your child. ~ Marjorie

    Enrollment Forms / Part 3: Sensorimotor Questionnaire
    Instructions: Below are a number of common problems that children have. Please rate each item according to your child’s behavior in the last month. For each item, ask yourself “How much of a problem has this been in the last month?”, and circle the best answer for each one. Please respond to all the items.

    If none, not at all, seldom, or very infrequently, you would select 0.
    If just a little true or only occasionally, you would select 1.
    If pretty much true, often or quite a bit, you would select 2.
    If very much true, or it occurs very often or frequently, you would select 3.
    1. Touch (Tactile)
    2. Balance and Movement (Vestibular/Proprioceptive)
    3. Coordination
    4. Muscle Tone
    5. Hearing (Auditory)
    6. Sight (Visual)
    7. Smell
    8. Attention and Behavior
    (Sensorimotor questionnaire compiled by Lynn A. Balzer-Martin, PhD, OTR)
    Once you have completed filling in the form please click/tab the SUBMIT button below. The information will be submitted and you will be directed back to the Enrollment Forms page. Please continue with Enrollment Forms / Part 4.
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