Please fill out this form and mail it to: Vision Audio Inc. 611 Anchor Dr. Joppa, MD 21085 Phone 1-888-213-7858 EASe (Electronic Auditory Stimulation effect) report Date of Report: ______________ Date EASe sessions began: ______________ Length of each session: ______________ Number of sessions per day: ______________ Number of days: ______________ Time of day per session: _______________________________________ What equipment did you use? _______________________________________ Where did you use it? _______________________________________ Did your child enjoy listening? ______________ What was the best thing about this program?____________________________ _______________________________________________________________________ _______________________________________________________________________ What was the worst thing about this program?___________________________ _______________________________________________________________________ _______________________________________________________________________ What results do you attribute to this program?_________________________ _______________________________________________________________________ _______________________________________________________________________ How long have the results lasted?______________________________________ _______________________________________________________________________ _______________________________________________________________________ Comments:______________________________________________________________ _______________________________________________________________________ _______________________________________________________________________