Rewired Kids — Logo Header

First Name *

Last Name *

Email *

Phone *

Child's Age *

By checking this box, I consent to receive non-marketing text messages from Rewired Kids about my child's assessment results, reminders to complete the assessment, program access, and replies to my questions. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, and new product updates from Rewired Kids at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

1. Which of these sounds most like what you’re dealing with right now? *

My child has big emotional reactions or struggles to calm down

My child seems clumsy or has trouble with coordination

My child struggles to focus, sit still, or finish tasks

My child has balance, posture, or sensory issues, or bedwetting

Not sure / a mix of a few of these

1. If you had to pick just one, which matters most right now?

Big emotional reactions or trouble calming down

Clumsy or trouble with coordination

Trouble focusing or finishing tasks

Balance, posture, sensory issues, or bedwetting

1. Does your child startle easily at loud noises or sudden movement? *

Yes

2. Has your child had bedwetting or daytime accidents after age 5? *

Yes

1. Does your child seem clumsy or uncoordinated when running, walking, or playing? *

Yes

2. Did your child skip crawling or crawl in an unusual way as a baby? *

Yes

1. Does your child have a hard time sitting still, even when they’re trying to? *

Yes

2. Does your child “collapse” at the desk or lose focus quickly? *

Yes

1. Does your child frequently walk on their toes or seem sensitive to socks/shoes/textures? *

Yes

2. Does your child have trouble with food textures or picky eating? *

Yes

How would you describe your child’s sleep most nights? *

Great

Okay

Struggles

On an average day, how much recreational screen time would you estimate? *

Under 1 hr

1–3 hrs

3+ hrs

Would you say meals and snacks at home are mostly homemade, mostly packaged, or a mix? *

Homemade

Packaged

Mix