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Understanding the Treatment
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Contact Us

Suite 21
Galway Clinic
Doughiska
Co. Galway
Republic of Ireland

email:
info@brainandbehaviour.ie

Phone:
1800 400 321

Hours:
Monday-Friday: 9am - 5pm

Submit questionnaire prior to contacting Brain & Behaviour Enhancement to support initial conversation

Please tick any of the symptoms you feel might be affecting your child:

Reading difficulties Poor spelling Writing problems Dyslexia Poor at sports Difficulty learning to ride a bicycle Dyspraxia Problem tying shoe laces Difficulty learning to blow nose Difficulty learning to swim Problem learning to skip Attention Deficit Disorder Low self-esteem Anxiety/panic attacks Travel sickness Concentration problem Poor organisation and planning Difficulty establishing and retaining friends Messy eating or spilling when pouring Losing or forgetting things Short attention span Dyscalculia Difficulty with rote learning

Your name:

Your surname:

Email address:

Contact number:

Child’s name:

Child’s age

Child’s class in school

Has the child been diagnosed with any condition?

Yes No

(If yes, please specify)

Please enter any further relevant details about the child:

Suite 21
Galway Clinic
Doughiska
Co. Galway
Republic of Ireland

Email: info@brainandbehaviour.ie
Phone: 1800 400 321
Hours: Monday - Friday: 9 - 5 pm

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Dr Mary F O’Connor, practising since 1994
Brain & Behaviour Enhancement © 2007

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