Submitter's First Name
Submitter's Last Name
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First Name of Participant For AIT
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Last Name of Participant For AIT
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Age of Participant for AIT
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Type
of Inquiry
(select main one)
Interested In AIT Services
AIT Checklist Online
AIT Listening Test Online
Schedule AIT Services
Professsional Practitioner Training
Other Inquiry
Is there a DIAGNOSIS or any
SUSPECTED DIAGNOSIS for any of these conditions for the Participant?
Mark the MAIN (1) diagnosis
that applies.
ADD
ADHD
Anxiety
Apraxia
Aspergers Syndrome
Attention Issues
Auditory Processing Disorder
Autism, ASD
Balance Issues
Behavioral Issues
Brain Injury or Trauma
Chemical Sensitivity
Concentration Difficulty
Depression
Downs Syndrome
Dyslexia
Dyspraxia
Hearing Loss
Epilepsy or Seizures
Hyperacute/Hypersensitive Hearing
Hyperlexia - Reading at very early age
Hyperactivity
Hypo-sensitive Hearing
Landau Kleffner Syndrome
Learning Disabilities
Math Difficulty
Noise or Sound Sensitivity
OCD - Obessive Compulsive Disorder
ODD - Oppositional Defiant Disorder
PDD - Pervasive Dev. Delay
PANDAS/PANS
Pyroluria - Zinc and B6 Deficiency
Reading Difficulty
Sensory Processing Disorder
Schizophrenia
Slow Response Time To Directions
Special Ed., 504, IEP
Speech and Language Delay
Tinnitus - Ringing in ears
Toxicity fron Heavy Metals
Vaccine Injury
Yeast Overgrowth
Other Not Listed
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