Please carefully read and submit the following form for pediatric occupational therapy. Occupational Therapy Intake "*" indicates required fields Child's Name* First Last Does your child have a nickname? Child's Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent Name* First Last Parent Phone Number*Parent Email Address:* Tell Us What Brought You HereWhich of the following areas of development do you feel your child is falling behind on or could use some help with?* Fine motor skills (hand-eye coordination & use of smaller hand muscles needed to grasp scissors, hold a pencil, use a fork, etc.) Gross motor skills (use of the large, core-stabilizing muscles needed for everyday functions like sitting upright, walking, running, jumping, balance, etc.) Activities of daily living (basic hygiene, self-care, executive function/organization, etc.) Sensory dysregulation Social/emotional communication Behavioral concerns Other Describe the primary concerns about your child that prompted you to seek assessment/treatment from an occupational therapist?*Explain any current physical limitations or developmental delays your child is experiencing?*List your child's current diagnosis or diagnoses.*List any special equipment your child uses, such as splints, braces, adaptive utensils or other.*If none, type N/A for not applicable.Do you have any feeding problems or nutritional concerns? Answer Yes or No. If yes, please describe.*Please check all that apply to your child.* Trach C-Line G-Tube Allergies Latex sensitivity Seizures Hearing aids Hearing difficulty Wears glasses Vision problems None of the above Does your child receive occupational therapy services at their school or daycare? If so, can you describe how that's been going : What progress have they made? Where do they continue to struggle?Any other aspects of your child's health, education, or overall wellbeing that their occupational therapist should know about?*If none, write N/AWhat are your child's strengths? What makes them special, interesting, awesome?*Social/Emotional DevelopmentDoes your child interact well with others?* Yes No Does your child have trouble making friends their age?* Yes No Detail your child's fears and coping behaviors.*Does your child have issues with self-injury during meltdowns?* Yes No Does your child struggle with:* Transitions (moving from one activity or place to to the next) Noise sensitivity Light sensitivity Sensory-seeking behaviors Sensory-avoiding behaviors Extreme picky eating Mood instability and meltdowns Difficulty calming/self-regulating when upset Sleep problems Executive function/organization Inattention Trouble following directions Always seems to be on-the-go Clumsiness and/or weak muscles Trouble following directions Difficulty following a routine Basic hygiene (hair brushing, teeth-brushing, bathing, age-appropriate toilet habits, etc.) Anxiety Constantly mouthing objects Eating things that aren't food Poor communication (speech, language, and social engagement) Other None of the above If you answered in the affirmative to the two previous questions, can you give us more details?If you have additional clinical or educational documentation pertaining to your child's diagnosis, treatment, or education that would be relevant for occupational therapy and that you did NOT already upload on the main Intake Form for All New Patients, please upload here. Drop files here or Select files Max. file size: 195 MB. Tell us what days, times, and location would be ideal for Occupational Therapy. (Ex: Anytime Monday-Thursday, 8a-3p, in-clinic)**While we cannot guarantee our availability will match your desired schedule exactly, we'll do our best! How did you hear about us?* Online search Social Media Brochure, flier, business card, or other printed media Recommended by friend or family member Referred by physician or other healthcare provider Other If you answered "other" to the previous question, please describe: Parent SignatureParent Signature* First Last By providing this electronic signature, I hereby affirm I am the parent/guardian of the aforementioned child, for whom I am legally authorized to make medical decisions. I agree to each of the above conditions as indicated, and certify all information contained in this form is complete and accurate to the best of my knowledge. I understand that an electronic signature is the legal equivalent of my manual/handwritten signature, and I am agreeing to all terms and conditions as indicated in this form.Date this form was completed:* Month Day Year Δ
