Occupational Therapy Intake Step 1 of 4 25% Parent/Guardian First Name* Parent/Guardian Last Name* Phone Number*Email Address* Patient's Name* First Last 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 Does your child receive school-based therapy? OT (Occupational Therapy) PT (Physical Therapy) Speech and Language Does your child receive special instruction or have an established IEP?* Yes No Does your child have a 504 Accommodation Plan?* Yes No Medical HistoryRemarkable diagnoses:*Known food allergies:*Special diet (i.e. gluten free, pureed food only, tube feeding, etc.):*Medical precautions:*Currently receiving services from other health care professionals: Psychologist PT (Physical Therapist) Speech and Language Therapist Nutritionist Behavioral Specialist Other Other: Developmental HistoryPlease check all the developmental milestones that your child has achieved: Rolling Sitting alone Creeping on all fours 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 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 If yes to any above, please describe. Social and Occupational HistoryPlease check how you would describe the following for your child. Socializes with family and close friends? Often Sometimes Rarely Not applicable Communicates needs and wants effectively? Often Sometimes Rarely Not applicable Hard to make friends? Often Sometimes Rarely Not applicable Tends to interact/play with younger children? Often Sometimes Rarely Not applicable Enjoys time alone? Often Sometimes Rarely Not applicable Tolerates change in routine? Often Sometimes Rarely Not applicable Tolerates running errands? Often Sometimes Rarely Not applicable Enjoys eating in restaurants? Often Sometimes Rarely Not applicable Enjoys attending birthday parties? Often Sometimes Rarely Not applicable Enjoys attending family gatherings? Often Sometimes Rarely Not applicable Please provide any additional information that you would like to share about your child. Person completing this intake form: First Name Last Name Relationship to child:
