This listening screening tool is provided to help you identify possible areas of weakness related to auditory functions through a sampling of related skills and behaviors. The results are not conclusive, nor is this intended as a diagnostic tool. This tool was developed to help you understand areas where The Listening Program® may be of particular benefit.  
   
 
 
Full Name: (person completing screening)
Relationship: (to person being screened...self, parent, teacher, etc)
Email:
Confirm Email:
 
First Name:(person being screened)


Last Name: (person being screened)
Birth Date: (mm/dd/yyyy)
/ /
Gender:
Male Female
Age:
Country:
Reason for Screening: (limit 2500 characters with spaces)
 
 
 
Please read each of the following statements and rate each as follows:

(0) Does not occur or apply due to age or circumstance
(1) If it never occurs
(2) If it occurs rarely
(3) If it occurs sometimes
(4) If it occurs often
(5) If it occurs always

1. Difficulty paying attention
0 1 2 3 4 5
2. Poor short-term memory
0 1 2 3 4 5
3. Poor reading comprehension
0 1 2 3 4 5
4. Difficulties spelling
0 1 2 3 4 5
5. Low academic/job performance
0 1 2 3 4 5
6. Difficulty starting and/or completing projects
0 1 2 3 4 5
7. Easily distracted in presence of background noise
0 1 2 3 4 5
8. Is oversensitive to certain sounds
0 1 2 3 4 5
9. Misunderstands directions or instructions
0 1 2 3 4 5
10. Confuses similar sounding words
0 1 2 3 4 5
11. Difficulty understanding jokes/puns/humor
0 1 2 3 4 5
12. Frequently asks "huh" or "what"
0 1 2 3 4 5
13. Difficulty discriminating sounds
0 1 2 3 4 5
14. Flat and monotonous voice quality
0 1 2 3 4 5
15. Speech lacks fluency and rhythm
0 1 2 3 4 5
16. Difficulty sounding out words
0 1 2 3 4 5
17. Mispronounces words
0 1 2 3 4 5
18. Difficulty summarizing a story/expressing thoughts
0 1 2 3 4 5
19. Hyperactivity
0 1 2 3 4 5
20. Has poor posture, including slouching or slumping
0 1 2 3 4 5
21. Has coordination problems
0 1 2 3 4 5
22. Difficulty with organization and planning
0 1 2 3 4 5
23. Is overwhelmed with sensory information
0 1 2 3 4 5
24. Confusion of right and left and/or location and direction
0 1 2 3 4 5
25. Lack of tactfulness
0 1 2 3 4 5
26. Poor social skills
0 1 2 3 4 5
27. Feels overburdened with everyday tasks
0 1 2 3 4 5
28. Low stress/frustration tolerance
0 1 2 3 4 5
29. Difficulty reading non-verbal communication
0 1 2 3 4 5
30. Poor self-image or low self-confidence
0 1 2 3 4 5
 
The information being collected in this listening screening tool is being recorded to a secure database for research purposes. This information will be viewable by a TLP Provider, if you elect to have them access this information. By selecting the submit button you agree to this information being used as described.