Questionnaire - Listen 4 Life

Does your child have difficulty following instructions?*
- Yes
- No
i.e.: need for repetition or visual cues to fully understand
Does your child often say “Huh?” “What?” or “Pardon”?*
- Yes
- No

Does your child have short attention span or get easily distracted?*
- Yes
- No
Are some 'normal' sounds too loud?*
- Yes
- No
i.e.: everyday noises like domestic or garden appliance, hand dryers in public toilets, etc.

Is listening difficult when there are background sounds?*
- Yes
- No
i.e.: Situations when you are in a shopping centre, restaurant or when the TV is on.
Do your child often daydream - 'away with the fairies' or not with it at times?*
- Yes
- No
i.e.: 'He is in his own world!'

Does your child have difficulty sitting still?*
- Yes
- No
i.e.: Increase in movement or fiddling when trying to pay attention.
Is your child clumsy, has poor balance or weak coordination?*
- Yes
- No
i.e.: avoids team sports

Does your child have poor handwriting or weak fine motor?*
- Yes
- No
Is your child below average in literacy or numeracy?*
- Yes
- No
i.e.: check your school report

Does your child confuse similar sounding words?*
- Yes
- No
Does your child often misunderstand the tone of voice?*
- Yes
- No
i.e.: a warning, someone beeing angry, firm, joking or sarcastic, etc.

Is your child slow to respond or react?*
- Yes
- No
Does your child struggle with daily routines?*
- Yes
- No
i.e.: getting ready for school or bed

Does your child have poor short term memory?*
- Yes
- No
Is your child disorganised or has weak planning skills?*
- Yes
- No
i.e.: struggles to start or complete homework, follow a recipe

Does your child underperform at school or work?*
- Yes
- No
i.e.: if you are bright with an auditory issue you will underperform but your teacher/supervisor may not notice
Is your child immature or has difficulty making or keeping friends?*
- Yes
- No
i.e.: if you are bright with an auditory issue you will underperform but your teacher/supervisor may not notice

Is your child easily overwhelmed?*
- Yes
- No
i.e.: may look away when beeing spoken to
Is your child anxious or emotional?*
- Yes
- No

Does your child have speech issues, speech delay or an odd voice?*
- Yes
- No
i.e.: quiet, loud, stutter, squeaky, flat monotone
Has your child difficulty clearly expressing thoughts or feelings?*
- Yes
- No
i.e.: is there lots locked inside?

Has your child low energy or are easily tired?*
- Yes
- No
Has your child low self-confidence?*
- Yes
- No
Self-confidence is how you feel about your abilities.

Has your child low self-esteem?*
- Yes
- No
Self-confidence is how you feel about yourself overall and how much positive regard or self-love you have.

Now we need your contact details so that we can send you the results. We will also send you more tips and advice on how to move to Guilt-Free Parenting™ and let your child rediscover the love of learning.
Name*
First Last
Email*
Phone Number*
Please type your number with country code and area code. e.g. +61 02 1234 5678 or 0043 09 1234 5678
In which country do you live?*
Country
Your childs first name:*
First
... or your own if you are filling this out for yourself.
Your childs age:*
... or your own if you are filling this out for yourself.
Email
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