MEFS qEEG BRAIN MAPPreview Intake FormYOUTH CEC 5-18Estimated time: 4 minutesField is required!Field is required!Field is required!Field is required!Field is required!Field is required!All fields are requiredShort Attention Span & Focus.NoneMildModerateSevereField is required!Field is required!Lack of Motivation/Poor Follow through.NoneMildModerateSevereField is required!Field is required!Procrastination/Puts Things Off.NoneMildModerateSevereField is required!Field is required!Difficulty with Decisions.NoneMildModerateSevereField is required!Field is required!Daydreams or Spaces Out.NoneMildModerateSevereField is required!Field is required!Careless Mistakes.NoneMildModerateSevereField is required!Field is required!Easily Distracted.NoneMildModerateSevereField is required!Field is required!Disorganization/Forgets & Loses Things.NoneMildModerateSevereField is required!Field is required!Socially Inappropriate.NoneMildModerateSevereField is required!Field is required!Poor Judgement.NoneMildModerateSevereField is required!Field is required!Poor Short Term Memory.NoneMildModerateSevereField is required!Field is required!Constant Worry.NoneMildModerateSevereField is required!Field is required!Sensitive To Light & Noises.NoneMildModerateSevereField is required!Field is required!List Learning Problems.NoneMildModerateSevereField is required!Field is required!Angry & Aggressive.NoneMildModerateSevereField is required!Field is required!Emotional Outbursts.NoneMildModerateSevereField is required!Field is required!Restless/Impatient/Easily Frustrated.NoneMildModerateSevereField is required!Field is required!Hyperactive.NoneMildModerateSevereField is required!Field is required!Argumentative.NoneMildModerateSevereField is required!Field is required!Oppositional.NoneMildModerateSevereField is required!Field is required!Personal Space Problems.NoneMildModerateSevereField is required!Field is required!Verbally Impulsive/Talks Rapidly.NoneMildModerateSevereField is required!Field is required!Shy & Anxious.NoneMildModerateSevereField is required!Field is required!Acts out of control.NoneMildModerateSevereField is required!Field is required!Event Sequence Problems.NoneMildModerateSevereField is required!Field is required!Forgetful.NoneMildModerateSevereField is required!Field is required!Monotone Speech.NoneMildModerateSevereField is required!Field is required!Scary Thoughts.NoneMildModerateSevereField is required!Field is required!Can't recall more than one request.NoneMildModerateSevereField is required!Field is required!Poor Math Skills.NoneMildModerateSevereField is required!Field is required!Poor reading comprehension.NoneMildModerateSevereField is required!Field is required!Trouble shifting attention.NoneMildModerateSevereField is required!Field is required!Whines Excessively.NoneMildModerateSevereField is required!Field is required!Stuck On Thoughts.NoneMildModerateSevereField is required!Field is required!Stuck on Behaviors.NoneMildModerateSevereField is required!Field is required!Bargains Constantly.NoneMildModerateSevereField is required!Field is required!Insomnia.NoneMildModerateSevereField is required!Field is required!Fearful Rumination.NoneMildModerateSevereField is required!Field is required!Needs Things Done A Certain Way.NoneMildModerateSevereField is required!Field is required!Misperception of Others.NoneMildModerateSevereField is required!Field is required!Doesn't Listen Carefully.NoneMildModerateSevereField is required!Field is required!Dyslexia.NoneMildModerateSevereField is required!Field is required!Reads Poorly.NoneMildModerateSevereField is required!Field is required!Poor Handwriting.NoneMildModerateSevereField is required!Field is required!Clumsy.NoneMildModerateSevereField is required!Field is required!Lacks Fine Motor Skills.NoneMildModerateSevereField is required!Field is required!Constantly Moving.NoneMildModerateSevereField is required!Field is required!Difficulty with Task Sequence.NoneMildModerateSevereField is required!Field is required!Difficulty Learning New Words.NoneMildModerateSevereField is required!Field is required!SendUnlock your Edge Now
