Occupational Therapy Intake Form | EBS Children's Therapy of Georgia

What are your primary concerns/goals for occupational therapy regarding your child?*

What are your child’s strengths?*

What are some of your child’s favorite things? Favorite play activities? Please, list any favorite characters, such as super heroes or cartoon characters, or any types of favorite song artists, as applicable.*

What makes your child happiest?*

Hand preference:*

School based therapy?

Does your child receive special instruction or have an established IEP?*

Or 504 Accommodation Plan*

Medical History

Remarkable Diagnoses:*

Known food allergies:*

Special Diet (Gluten free, pureed food only, tube feeding, etc.):*

Medical precautions:*

Currently receiving services from other health care professionals:

Psychologist
PT
Speech and Language
Nutritionist
Behavioral Specialist
Other

Developmental History

Please check all the developmental milestones that your child achieved:

Developmental milestones were met:*

Areas of special concern regarding developmental milestones:*

Please select the amount of assistance needed for your child to complete the following:

Using Spoon

Using Fork

Using Knife

Puncturing straw in drink

Grooming

Brushing Teeth

Bathing

Upper Dressing

Lower Dressing

Snaps

Shoes on

Shoes off

Tying shoes

Socks on

Socks off

Toileting

Other concerns:

Please select if you would describe the following as remarkable for your child:

Mostly quiet

Overly active

Tires easily

Talks constantly

Too impulsive

Restless

Clumsy

Nervous ticks/habits

If applicable, describe:

Wets bed

Poor attention

Frustrated easily

Unusual fears

Rocks self frequently

Mostly quiet

Stubborn

Resistant to change

Fights frequently

Usually happy

Exhibits temper tantrums

Difficulty falling asleep

Difficulty staying asleep

Sluggish in the mornings

Social and Occupational History

Please check how you would describe the following for your child:

Socialize with family and close friends?

Communicate needs and wants effectively?

Hard to make friends?

Tend to interact/play with younger children?

Enjoy time alone?

Tolerate change in routine?

Tolerate running errands?

Enjoy eating in restaurants?

Attending birthday parties?

Attending family gatherings?

Please provide any additional information that you would like to share about your child:

Child's Name

First Last

Person Completing this intake form:

First Last

Email

Phone