Cognitive Processing Disorder Screening Form
Personal Information
Full Name
Date of Birth
Email Address
Phone Number
Screening Questions
Do you often have trouble following instructions or remembering directions?
Yes
No
Do you frequently have difficulty understanding spoken or written language?
Yes
No
Do you experience challenges processing information quickly?
Yes
No
Do you often find it difficult to focus or pay attention, especially in noisy environments?
Yes
No
Are there any other cognitive challenges you experience?
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