🧠 Assessment Form

Brain & Behaviour
Assessment System

📋

Client Intake

🎮

Gaming (GASA)

🧩

Cognitive / IQ

💛

Emotional (EQ)

🏃

Physical Health

Step 1

Client Intake Form

Fill in details for both child and parent/guardian.

👦 Child's Information

Full Name *

Age *

Class / Profession

Gender

Daily Screen Time (hrs)

Sleep per night (hrs)

Academic/Job Satisfaction

Other hobbies / interests

👩 Parent / Guardian

Parent's Name *

Relationship

Occupation

Phone

Main concern

Step 2 — Gaming Behaviour

Game Addiction Scale (GASA)

Rate how often each statement applies. Ask the child to answer honestly.

⚠️ Rate each item: 1 = Never → 5 = Very Often ·

Step 3 — Cognitive Profile

Cognitive & IQ Assessment

Rate the child based on observation and parent's report.

Step 4 — Emotional State

Emotional Quotient (EQ) Screening

Assess the child's emotional and social wellbeing.

Step 5 — Physical Health

Physical Health & Lifestyle Check

Physical health directly impacts brain function and cognitive performance.

Assessment Report for

—

💰 Recommended Fee Structure

First Assessment Session (Today — Complimentary)	₹0
Individual Brain Gym Session (45 min)	₹400 – ₹600
4-Week Pilot Program (8 sessions)	₹3,500
Monthly Progress Report	₹300
Recommended: 4-Week Starter Package	₹3,800

📊 Export to Excel Tracker

This student's complete data row is ready to be added to Bhāva Tech_Student_Tracker.xlsx. Click below — a pre-filled Excel row file will download. Open your Master Tracker → go to 📋 Student Records sheet → paste the row at the bottom.

✅ Excel row downloaded! Open Bhāva Tech_Student_Tracker.xlsx → Student Records → paste at bottom.

Start a new assessment for the next student.

Brain & BehaviourAssessment System