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Home
Services
Adult Services
Swallowing Disorders or Dysphagia
Post-Stroke Rehabilitation
Cognitive-Communication Disorders
Accent Reduction/Modification
Voice Disorders
Pediatric Services
Speech And Language Therapy
Occupational Therapy
Feeding Therapy
Reading/Dyslexia, Auditory Processing, And Listening Skills
Social Skills Groups
Early Intervention
About Us
Our Team
Our Treatment Approach
Forms
Blog
Contact
Occupational Therapy Intake Form
Home
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Forms
/ Occupational Therapy Intake Form
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:
*
Right
Left
Both
Unknown
School based therapy?
OT
PT
Speech and Language
Does your child receive special instruction or have an established IEP?
*
No
Yes
Or 504 Accommodation Plan
*
Yes
No
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:
Rolling sitting alone
Creeping on all 4’s
Pull to stand
Walking
Eating with a spoon
Hopping on one foot
Finger feeding
Cutting with a knife
Cutting with scissors
Jumping
Riding a bike
Developmental milestones were met:
*
Within typical age ranges
Delayed
Areas of special concern regarding developmental milestones:
*
Please select the amount of assistance needed for your child to complete the following:
Using Spoon
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Using Fork
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Using Knife
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Puncturing straw in drink
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Grooming
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Brushing Teeth
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Bathing
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Upper Dressing
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Lower Dressing
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Snaps
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Shoes on
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Shoes off
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Tying shoes
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Socks on
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Socks off
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Toileting
No Help Needed
Only Needs Supervision
Needs 25% Help
Needs 50% Help
Needs 75% Help
Needs 100% Help
Other concerns:
Please select if you would describe the following as remarkable for your child:
Mostly quiet
Yes
No
Sometimes
Not applicable
Overly active
Yes
No
Sometimes
Not applicable
Tires easily
Yes
No
Sometimes
Not applicable
Talks constantly
Yes
No
Sometimes
Not applicable
Too impulsive
Yes
No
Sometimes
Not applicable
Restless
Yes
No
Sometimes
Not applicable
Clumsy
Yes
No
Sometimes
Not applicable
Nervous ticks/habits
Yes
No
Sometimes
Not applicable
If applicable, describe:
Wets bed
Yes
No
Sometimes
Not applicable
Poor attention
Yes
No
Sometimes
Not applicable
Frustrated easily
Yes
No
Sometimes
Not applicable
Unusual fears
Yes
No
Sometimes
Not applicable
Rocks self frequently
Yes
No
Sometimes
Not applicable
Mostly quiet
Yes
No
Sometimes
Not applicable
Stubborn
Yes
No
Sometimes
Not applicable
Resistant to change
Yes
No
Sometimes
Not applicable
Fights frequently
Yes
No
Sometimes
Not applicable
Usually happy
Yes
No
Sometimes
Not applicable
Exhibits temper tantrums
Yes
No
Sometimes
Not applicable
Difficulty falling asleep
Yes
No
Sometimes
Not applicable
Difficulty staying asleep
Yes
No
Sometimes
Not applicable
Sluggish in the mornings
Yes
No
Sometimes
Not applicable
Social and Occupational History
Please check how you would describe the following for your child:
Socialize with family and close friends?
Often
Sometimes
Rarely
Not applicable
Communicate needs and wants effectively?
Often
Sometimes
Rarely
Not applicable
Hard to make friends?
Often
Sometimes
Rarely
Not applicable
Tend to interact/play with younger children?
Often
Sometimes
Rarely
Not applicable
Enjoy time alone?
Often
Sometimes
Rarely
Not applicable
Tolerate change in routine?
Often
Sometimes
Rarely
Not applicable
Tolerate running errands?
Often
Sometimes
Rarely
Not applicable
Enjoy eating in restaurants?
Often
Sometimes
Rarely
Not applicable
Attending birthday parties?
Often
Sometimes
Rarely
Not applicable
Attending family gatherings?
Often
Sometimes
Rarely
Not applicable
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
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