Therapy

Date

Location of Service

Child Name

Ex: (First) (M.I.) (Last)

Date of Birth

(Mm/dd/yy)

Mailing Address:

City

State

ZIP

Mothers Name

Email

Home Phone

Cell Phone

Work Phone

Fax

Address (if different from above)

Fathers Name

Email

Home Phone

Cell Phone

Work Phone

Fax

Address (if different from above)

Preferred method of contact

Emergency Contacts 1

Name other than parent

Relationship

Home Phone

Cell Phone

Emergency Contacts 2

Name other than parent

Relationship

Home Phone

Cell Phone

Medical

Childâ€™s current primary physician

City

Phone

Medications/Restrictions

Medical Diagnosis

List any precautions (i.e., medications, activities, foods, etc.).

Current school attending:

School Background Information

Phone:

City:

District

Teacher Name:

Grade:

Aide/shadow

What type of classroom setting?

Previous school(s) attended:

At what age did your child start receiving OT?

Therapy History - Occupational Therapy

Where is your child currently receiving OT?

Occupational Therapy

How many times per week?

Occupational Therapy

Please list where your child has had services in the past:

Occupational Therapy

What goals/issues were addressed?

Occupational Therapy

At what age did your child start receiving PT?

Physical Therapy

Where is your child currently receiving PT?

Physical Therapy

How many times per week?

Physical Therapy

Please list where your child has had services in the past

Physical Therapy

What goals/issues were addressed?

Physical Therapy

At what age did your child start receiving speech therapy?

Speech Therapy

Where is your child currently receiving speech therapy?

Speech Therapy

How many times per week?

Speech Therapy

Please list where your child has had services in the past:

Speech Therapy

What goals/issues were addressed?

Speech Therapy

Has your child had a recent vision test?

Yes

No

Does he or she wear glasses?

Yes

No

Has your child had a recent hearing test?

Yes

No

Checkboxes

Option 1

Option 2

Does your child have a history of seizures?

Yes

No

1. When was the most recent seizure?

2. What type of seizure(s) has your child experienced?

3. What medication(s) have been prescribed?

Please list all childhood illnesses:

List any surgeries and the age of your child when they occurred:

Complications, illnesses, or infections during pregnancy?

Yes

No

If yes please explain:

Complications during Labor and/or delivery?

Yes

No

If yes please explain:

Was your child born:

Prematurely

Yes

No

At full term?

Yes

No

Birth weight?

Breast Fed?

Yes

No

If yes, for how long?

Were there problems with feeding?

Yes

No

Were there problems with Breathing?

Yes

No

Were there problems with Sleeping?

Yes

No

Please explain:

Developmental milestones

Roll over

Crawl

First word

Say Sentences

Single Line Text

Sit

Walk

Run

Jump

Throw

Ride bike

Skip

Has your child established a preferred hand for fine motor tasks?

Has your child established hand dominance?

Yes

No

If yes which one?

Does your child receive behavioral intervention (i.e. ABA)?

Behavioral

What company is currently providing these services?

Behavioral

How many hours per week is your child receiving behavioral therapy?

Behavioral

Does your child routinely demonstrate inappropriate behavior?

Yes

No

If yes, what behavior(s)?

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