Sensory Kids New Client
Child's Name
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First
Last
Gender
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Male
Female
Other
Date of Birth
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Age
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School
Grade Level
School/Daycare Schedule
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Please List Preferred Days/Times for Therapy
Address
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Street Address
City
State / Province
Postal / Zip Code
Email for Appointment Reminders
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example@example.com
How did you hear about Sensory Kids?
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Services you are interested in pursuing with Sensory Kids
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Feeding Therapy
Speech and Language Therapy
Occupational Therapy
Language(s) Spoken at Home
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Health Care Provider Name (Pediatrician) and Phone Number
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ALLERGIES
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YES
NO
IF YES, PLEASE LIST
MEDICATIONS
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YES
NO
IF YES, PLEASE LIST
DIAGNOSIS
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YES
NO
IF YES, PLEASE LIST DIAGNOSIS
DATE OF DIAGNOSIS
DIAGNOSIS PROVIDED BY
Name of Physician/Provider
I have the legal right to give permission for therapy services, because my relationship to the child is:
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Custodial parent
Legal guardian
DHS caseworker
Parent/Guardian Name - Primary
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First Name
Last Name
Parent/Guardian Preferred Pronouns
Phone Number - Primary
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email- Primary
*
example@example.com
Parent/Guardian Employer - Primary
Parent/Guardian Name - Secondary
First Name
Last Name
Phone Number - Secondary
Please enter a valid phone number.
Format: (000) 000-0000.
Email- Secondary
example@example.com
Parent/Guardian Employer - Secondary
Parent/Guardian Preferred Pronouns
Voice/Text Message Approval
*
CHECK HERE IF IT'S OK TO LEAVE MESSAGES FOR ALL PARTIES LISTED ABOVE
Who will be involved in the child's therapy?
(List names and relationships of everyone in the home)
Is there anything I need to know about contacting the people listed above?
Custody arrangements, divorce stipulations, etc
Emergency Contact (When neither guardian can be reached)
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First Name
Last Name
Emergency Contact Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship to Child
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Please list other professionals your child has worked with in the past (therapist tutors, counselors etc.) Name, Phone, Currently working with?
Describe your reason for seeking Occupational Therapy/Speech Therapy services, how long has this reason influenced you/your life?
What have you tried to do to resolve these matters on your own? In what way(s) was this helpful?
Labor and Delivery Information
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Born Full-Term
Born Premature
Childs Birth Weight
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Gestational Age
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By Week
Please describe any pregnancy or birth complications
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Feeding
Breastfed
Formula fed
Combination
Feeding comments (i.e. picky eater, swallowing difficulties etc.)
Did child meet all developmental milestones? (i.e. crawling, walking, etc.)
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YES
NO
Does your child have any medical conditions?
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Yes
No
If yes, describe condition (G-tube, seizures, diabetes, juvenile arthritis, etc)
List hospitalizations, surgeries, and injuries (broken bone, tonsillectomy, concussion, etc) with dates
Recent testing (MRI, swallow study, x-rays, hearing test, ADHD, IQ, genetic testing, etc.)
Are you transferring services or adding additional services from another provider?
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Transferring Services
Adding Services
None of the above
If Transferring or adding please tell us where from.
What are your thoughts about how Sensory Kids may be able to help?
Please share anything you think is important for us to know that we may have missed:
Please list your Child’s Strengths
Does your child have an IEP?
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Yes
No
In Process
Please fill out the following if you are interested in speech therapy:
Any skills they have acquired and then lost? How is your child with turn taking/direction following? How do they interact with other children?
Does your child become frustrated if they are unable to communicate their wants/needs? What does that look like?
Are you concerned about your child's speech sound production? If so, please explain.
Did your child use 1 word by the age of 1 year?
YES
NO
Did you child begin using 2 words by the age of 2 years old?
YES
no
Does your child currently speak using 3+ word sentences?
YES
NO
Approximately how many words does your child currently have?
Does your child currently use sign or gestures to communicate?
YES
NO
If yes, what signs/gestures?
Does your child currently use a communication device to speak?
YES
NO
If yes, what device?
Does your child try to get you to notice interesting objects?
YES
NO
When you point to a toy across the room, does your child look at it?
YES
NO
Does your child engage in pretend play with toys (i.e. feed a doll?)
YES
NO
Does your child play well with other children?
YES
NO
Do you have any concerns regarding socialization? If yes, please explain.
How does your child communicate in different settings? Home, community, school, etc.?
Did child pass newborn hearing screening?
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YES
NO
Has your child had a history of ear infections or tubes placed.
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Has your child had hearing testing done since the newborn screening? If so please list results. (Date of testing)
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Is there a history of speech/language delays on either paternal or maternal side. (i.e. Speech or Language, Stuttering, Hearing loss, Cleft Palate, Autism Spectrum, Developmental Delay, Reading or Learning Disability, ADHD). If yes, please explain.
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Parent/Guardian Signature
Submit
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