Mindful-ish Reflex Integration Screening Parent Questionnaire

Reflex Integration Screening Parent Questionnaire

"*" indicates required fields

1Child Information

2Birth & Early History

3Early Movement Milestones (Birth to Walking)

4Movement & Coordination

5Sensory Experiences

6Self-Regulation & Emotions

7Communication & Focus

8Tell Us More

9Terms & Agreement

Company

This field is for validation purposes and should be left unchanged.

Child's Name:*

Date of Birth*

MM slash DD slash YYYY

My child was born*

vaginally

by C-section

My child’s labor was induced.*

yes

My child was born premature (before 37 weeks).*

yes

My child spent time in the NICU.*

yes

My child disliked tummy time as a baby.*

yes

My child was colicky or cried frequently as an infant.*

yes

My child preferred being held upright rather than lying on their tummy.*

yes

My child was diagnosed with or suspected to have a tongue or lip tie (trouble nursing, bottle-feeding, or moving tongue freely).*

yes

My child lifted their head while on their tummy by 3–4 months.*

yes

My child rolled over on their own by 6 months.*

yes

My child sat up without support by 6–8 months.*

yes

My child crawled on hands and knees before walking.*

yes

My child preferred scooting or rolling instead of crawling.*

yes

My child pulled to stand and cruised along furniture by 10–12 months.*

yes

My child walked independently between 12 and 15 months.*

yes

My child walked before crawling.*

yes

My child continued crawling after learning to walk (for play or fun).*

yes

My child seemed to skip or rush through early movement stages.*

yes

My child seemed hesitant or fearful about standing or walking.*

yes

My child has frequent falls, bumps into things, or seems clumsy.*

yes

My child appears uncoordinated or “floppy.”*

yes

My child’s body sometimes looks or feels tight, stiff, or tense when moving.*

yes

My child has difficulty using both hands together (clapping, catching, cutting).*

yes

My child has trouble crossing midline (reaching across body, twisting).*

yes

My child tires easily during play or physical activity.*

yes

My child has poor posture or slumps when sitting or standing.*

yes

My child avoids or seeks intense movement (spinning, jumping, swinging).*

yes

My child gets carsick or disoriented with motion.*

yes

My child struggles with clothing textures, tags, or getting dressed.*

yes

My child dislikes hair washing, tooth brushing, or face wiping.*

yes

My child mouths objects or chews clothing.*

yes

My child startles easily with loud sounds or unexpected touch.*

yes

My child seems unusually sensitive to light, sound, or smell.*

yes

My child has trouble sitting still or staying in one position.*

yes

My child is fidgety or constantly in motion.*

yes

My child is easily frustrated or emotionally reactive.*

yes

My child struggles with changes in routine or transitions.*

yes

My child has difficulty calming down after becoming upset.*

yes

My child often seems anxious or hesitant to try new things.*

yes

My child’s speech sounds delayed or unclear for their age.*

yes

My child has difficulty focusing or following directions.*

yes

My child seems to “zone out” or daydream during activities.*

yes

My child can play independently without needing constant entertainment.*

yes

My child moves quickly from one activity to another and has trouble finishing tasks.*

yes

What are your top concerns or questions about your child’s movement, coordination, or behavior?

What strengths or activities does your child enjoy most?

Anything else you feel is important to share?

Signing Parent / Guardian Name*

First Last

Signing Parent / Guardian Email Address*

Parent/Guardian Consent*

I give permission for my child to participate in the Reflex Integration Screening at Downtown Jewish Preschool (DJP).

I understand that this screening is observational and educational. It is not a medical evaluation or diagnostic assessment, but a tool to help guide a holistic approach to supporting my child’s development.

Note: After submitting this questionnaire, you will be redirected to a signature page to confirm authorization.

Billing Address

Street Address City State ZIP Code

Credit Card

Cardholder Name

Card Details

Screening Fee

Price:

Total

Reflex Integration Screening Parent Questionnaire

"*" indicates required fields

1Child Information

2Birth & Early History

3Early Movement Milestones (Birth to Walking)

4Movement & Coordination

5Sensory Experiences

6Self-Regulation & Emotions

7Communication & Focus

8Tell Us More

9Terms & Agreement

URL

This field is for validation purposes and should be left unchanged.

Child's Name:*

Date of Birth*

MM slash DD slash YYYY

My child was born*

vaginally

by C-section

My child’s labor was induced.*

yes

My child was born premature (before 37 weeks).*

yes

My child spent time in the NICU.*

yes

My child disliked tummy time as a baby.*

yes

My child was colicky or cried frequently as an infant.*

yes

My child preferred being held upright rather than lying on their tummy.*

yes

My child was diagnosed with or suspected to have a tongue or lip tie (trouble nursing, bottle-feeding, or moving tongue freely).*

yes

My child lifted their head while on their tummy by 3–4 months.*

yes

My child rolled over on their own by 6 months.*

yes

My child sat up without support by 6–8 months.*

yes

My child crawled on hands and knees before walking.*

yes

My child preferred scooting or rolling instead of crawling.*

yes

My child pulled to stand and cruised along furniture by 10–12 months.*

yes

My child walked independently between 12 and 15 months.*

yes

My child walked before crawling.*

yes

My child continued crawling after learning to walk (for play or fun).*

yes

My child seemed to skip or rush through early movement stages.*

yes

My child seemed hesitant or fearful about standing or walking.*

yes

My child has frequent falls, bumps into things, or seems clumsy.*

yes

My child appears uncoordinated or “floppy.”*

yes

My child’s body sometimes looks or feels tight, stiff, or tense when moving.*

yes

My child has difficulty using both hands together (clapping, catching, cutting).*

yes

My child has trouble crossing midline (reaching across body, twisting).*

yes

My child tires easily during play or physical activity.*

yes

My child has poor posture or slumps when sitting or standing.*

yes

My child avoids or seeks intense movement (spinning, jumping, swinging).*

yes

My child gets carsick or disoriented with motion.*

yes

My child struggles with clothing textures, tags, or getting dressed.*

yes

My child dislikes hair washing, tooth brushing, or face wiping.*

yes

My child mouths objects or chews clothing.*

yes

My child startles easily with loud sounds or unexpected touch.*

yes

My child seems unusually sensitive to light, sound, or smell.*

yes

My child has trouble sitting still or staying in one position.*

yes

My child is fidgety or constantly in motion.*

yes

My child is easily frustrated or emotionally reactive.*

yes

My child struggles with changes in routine or transitions.*

yes

My child has difficulty calming down after becoming upset.*

yes

My child often seems anxious or hesitant to try new things.*

yes

My child’s speech sounds delayed or unclear for their age.*

yes

My child has difficulty focusing or following directions.*

yes

My child seems to “zone out” or daydream during activities.*

yes

My child can play independently without needing constant entertainment.*

yes

My child moves quickly from one activity to another and has trouble finishing tasks.*

yes

What are your top concerns or questions about your child’s movement, coordination, or behavior?

What strengths or activities does your child enjoy most?

Anything else you feel is important to share?

Signing Parent / Guardian Name*

First Last

Signing Parent / Guardian Email Address*

Parent/Guardian Consent*

I give permission for my child to participate in the Reflex Integration Screening at Downtown Jewish Preschool (DJP).

Note: After submitting this questionnaire, you will be redirected to a signature page to confirm authorization.

Billing Address

Street Address City State ZIP Code

Credit Card

Cardholder Name

Card Details

Screening Fee

Price:

Total

Reflex Integration Screening Parent Questionnaire

Note: After submitting this questionnaire, you will be redirected to a signature page to confirm authorization.

Reflex Integration Screening Parent Questionnaire

Note: After submitting this questionnaire, you will be redirected to a signature page to confirm authorization.

Fran Rubio-Katz