I have enrolled my child _________________________ in the Brain Balance Program.

The Brain Balance Program is a unique program which utilizes a comprehensive

multi- faceted approach designed specifically to address the various difficulties
exhibited or experienced by each child. Brain Balance consistently incorporates the
latest information available from current brain research as a means to continuously
improve their abilities to address these complex conditions. It has been their
experience that most children with academic and/or behavioral issues suffer in a
variety of the following categories: motor issues, visual-spatial-organizational issues,
social abilities, sensory issues, immunity dysfunction and cognitive dysfunction.
A representative from Brain Balance will be contacting you in the near future to
make arrangements for a short informal meeting. This will initiate the team
approach utilized by Brain Balance. This meeting will address your concerns and
will help us to develop a team strategy that will benefit my child.

Authorization to Release Student Information

I
, agree to allow Brain
Balance
Achievement Centers, and its employees, to speak to a third party in terms of my
child, ________________________________________ regarding his/her progress in
the Brain Balance Program. I also understand that Brain Balance may make
recommendations to the third party to ensure the childs success.

School:

_______Phone Number:

Teacher(s):
Parent/Guardian (Print):

________________

Parent/Guardian (Sign):

Date

Director Signature:

Date
(Center Copy)

TEACHER VISIT APPOINTMENT FORM

*Please have your childs teacher fill this out with in first week of program!
Brain Balance will be working with one of your students. We would like the
opportunity to meet with you and explain how the Brain Balance Program works.
Through this combined effort, we can help your student succeed and reach their full
potential.
Student Name:
School Name:
School Address:
Teacher Name:
Teacher Email:
Teacher Phone#
Teacher Preferred Contact:
Please check one
Teacher Preferred Days to
Meet:
Please circle

Email

Phone

Th

Please list specific times that work works best

for you:

Please complete and return to parent.

Were looking forward to meeting with you!

Call

Visit

Learn More

413-737-5439

1472 Riverdale Street

West Springfield, MA
01089

lfinkbeiner@brainbalancecenters.com
brainbalancewestspringfield.com

Teacher Assessment
Teachers Name

____

School

Date _

Phone number ____________________ Email address ____________________________

Students name

Grade

In an effort to gain a complete picture of the difficulties a child may be experiencing we

request that all of our students teachers complete the following assessment. This form will
enable us to institute strategies which will help your student achieve both academically and
behaviorally. It has been our experience that a team approach always provides the best
results. This team includes the student, his parents, his teachers and our staff of Directors,
Sensory Motor Coaches and Special Educators. We will be contacting you within the near
future to plan a brief meeting so we can discuss your concerns and develop our team
strategies to address them.
Thank you for your cooperation,
Talitha Abramsen
Center Director

Linda Litwinovich
Assistant Director

Rebecca Morsch
Program Director

Grading system of 0-10 ( 0=does not apply 10=very severe)

Teacher Assessment
Teachers Name

____

School

Date _

Phone number ____________________ Email address ____________________________

Students name

Grade

In an effort to gain a complete picture of the difficulties a child may be experiencing we

request that all of our students teachers complete the following assessment. This form will
enable us to institute strategies which will help your student achieve both academically and
behaviorally. It has been our experience that a team approach always provides the best
results. This team includes the student, his parents, his teachers and our staff of Directors,
Sensory Motor Coaches and Special Educators. We will be contacting you within the near
future to plan a brief meeting so we can discuss your concerns and develop our team
strategies to address them.
Thank you for your cooperation,
Talitha Abramsen
Center Director

Linda Litwinovich
Assistant Director

Rebecca Morsch
Program Director

Grading system of 0-10 ( 0=does not apply 10=very severe)