Occupational Therapy Intake Form

This form is HIPPA compliant and encrypted so your information will be kept secure!

Family Information

Child's full name

Nickname

Date of Birth

Age

Male or Female

Male Female

Parent/Guardian

Phone

Parent/Guardian

Phone

Preferred Methods of Communication

Call

Text

Leave Message OK?

Sibling

Age

Therapy received (OT, PT, SLP, SW)

Sibling

Age

Therapy received (OT, PT, SLP, SW)

Sibling

Age

Therapy received (OT, PT, SLP, SW)

Sibling

Age

Therapy received (OT, PT, SLP, SW)

Does your child have an IEP?

Yes No

What services does your child receive at school through their IEP?

Has your child ever received occupational, physical, or speech therapy?

Yes No

If YES, please list the type of therapy, length of services, and what was addressed:

Is your child currently receiving occupational therapy services?

Yes No

If YES, please list providers, locations, and days/times:

Medication and Allergies

List all current medications, including prescriptions, over the counter medications, vitamins, and/or homeopathic medications:

Allergy

Reaction

Allergy

Reaction

Allergy

Reaction

Diagnoses—List any known medical diagnoses or medical conditions and dates of diagnosis:

Does your child wear glasses/corrective lenses?

Yes No

When was the last vision exam?

Pregnancy and Delivery

Did the child’s mother have any illnesses or complications during pregnancy or delivery?

Yes No

If yes, please describe

Was your child premature?

Yes No

Born how many weeks of gestation?

Did your child require any medical procedures before, during, or after birth? Please describe:

Motor Development

Age child began crawling

Age sitting up unassisted

Walking unassisted

Do you have any concerns regarding your child's gross motor skills (walking up/down stairs, running smoothly, etc.)??

Yes No

If yes, please explain

Do you have any concerns regarding your child’s fine motor skills (handwriting, cutting, managing clothing fasteners, etc.)?

Yes No

If yes, please explain

FEEDING/EATING/SELF-HELP SKILLS

Did your child have any feeding issues as an infant?

Yes No

If yes, please describe

Did your child have colic/reflux issues?

Yes No

If yes, please describe

Does your child have a special diet (e.g., GFCF, lactose intolerance, etc.)?

Yes No

If yes, please describe

Do you have any concerns regarding your child’s appetite or nutrition?

Yes No

If yes, please describe

Do you have any concerns regarding their feeding and eating skills (using a spoon/fork, drinking through a straw, chewing/swallowing, etc.)?

Yes No

If yes, please describe

Do you have any concerns regarding food choices (e.g., eats only certain foods)?

Yes No

If yes, please describe

Do you have any concerns regarding their dressing skills (getting dressed/undressed, managing buttons/snaps/zippers, shoe tying, etc.)?

Yes No

If yes, please describe

Do you have any concerns regarding their hygiene skills (e.g., tooth brushing, bathing, hand washing, etc.)?

Yes No

If yes, please explain

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

Takes off pants