Milestones Occupational Therapy Intake Form

Milestones Occupational Therapy Intake Form
Today's Date*

MonthDayYear
Date
Name of Patient *

First NameLast Name
Name of Parent/Guardian*

First NameLast Name
Email*
example@example.com
Patient's DOB*
Funding Source*
(If you selected insurance, please complete the next two questions with policy information. If you selected private pay, please write N/A for both questions below.)
Insurance Provider *
(if you selected private pay above, write N/A)
Patient's Insurance ID or Contract Number*
(if you selected private pay above, write N/A)
Insurance Group Number
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Phone Number*

Area CodePhone Number
Pediatrician Name
Pediatrician Phone Number

Area CodePhone Number
Pediatrician Fax Number

Area CodePhone Number
What is the patient's primary language?
Who is the patient's primary caregiver?
Diagnoses ex; Autism, Speech Delay, etc*
If no diagnosis, type N/A. Insurance will not cover ABA without a formal Autism diagnosis and report
Diagnosis Date

MonthDayYear
Date
Parent/Guardian Concerns *
Does your child receive ABA therapy? If so, please list the days/times.
Primary reason for bringing the child for this evaluation:
When did you first notice the issue(s)?
Is there any known history of the following in immediate or extended family?

AutismADHDLearning DisabilitiesHearing LossSpeech/Language DelaysMotor IssuesFeeding issues
MOTOR DEVELOPMENT: List approximate age at which your child began crawling
Sat up:
Started to walk:
Walked unassisted:
Any concerns regarding gross motor skills (i.e., walking up/down stairs, running smoothly)?If yes, please explain:
Any concerns regarding fine motor skills (i.e., stacking blocks, drawing, cutting, writing)? If yes, please explain:
SELF-HELP SKILLS CONCERNS: Check all that apply

Any concerns regarding feeding and eating skills (i.e., using spoon/fork, drinking through straw, foodchoices, ability to chew/swallow)?Any concerns about food choices (i.e., selective eater, eats only certain foods or textures)?Any concerns regarding dressing skills (i.e., getting dressed/undressed, managing buttons/snaps/zippers,shoe tying)Any concerns regarding hygiene skills (i.e. tooth brushing, bathing, combing hair)?
SENSORY CONCERNS. PCheck all that apply.

Frequently trips on his/her own feetWalks on his/her toesFrequently bumps into furniture, walls, or other peopleUnaware of being touched or bumped unless done with extreme forceUnaware of that face or hands are dirty (i.e., nose running, food on face)Seems unsure of how to move his/her body; is clumsy and awkwardSlumps or slouches when sitting; places head on hand when sittingHas difficulty learning new motor tasksIs in constant motionHas difficulty sitting stillChews on pens, straws, shirts, etcFrequently touches people and objectsFrequently gets in everyone else’s spaceIs overly sensitive to touch, noise, smells, etcAvoids touching certain texturesAvoids messy play (i.e., finger paints, playdough, mud, sand)Only eats certain foods or food texturesIs sensitive to clothing tags or texturesComplains about having hair brushedResists having teeth brushedDoes not like to have fingernails trimmedRefuses to walk barefootHas trouble falling asleep or staying asleepGets “stuck” on toy or task and has difficulty changing to another taskIs fearful on swingsIs fearful of slide or other playground structuresIs fearless on playground equipment
What is your child's most difficult problem at home and/or school?
How does your child respond to being misunderstood or unable to communicate?
Pregnancy and Birth History
Were there any complications during the pregnancy or birth? If yes, please describe.
How long was the pregnancy in weeks?
Was labor and delivery normal? Please describe any difficulties.
Was oxygen or respiratory assistance required after birth? If yes, please describe.
What was the child's birth weight?
Did the child experience any complications with feeding? If yes, please describe.
How was the child fed as an infant and until what age? Bottle/breast
Medical History:
Has your child experienced any of the following? (check all that apply)

adenoidectomyallergiesbreathing difficultiescoldsear infectionsear tubesvision problemssleeping difficultiesseizureshead injurytonsillitistonsillectomy
Does your child have any allergies? Please list
Is your child currently taking medications? If so, please list
Has your child's hearing been evaluated recently? If yes, what were the results?
Has your child's vision been evaluated recently? If yes, what were the results?
Does your child have any difficulties eating/swallowing? If yes, please describe. (ex: picky eater, food sensitivities, choking/gagging, etc.)
Speech and Language Development
List approximate age the child achieved the following developmental milestones: Said first words:blanks . Put 2+ words together: blank . Babbled: Toilet trained:
How would you describe how your child currently communicates? (e.g., sounds (grunting/vowels), gestures (pointing), words (up, no, more), 2 to 4 word sentences, sentences longer than four words, etc.)
Do you have a difficult time understanding your child's speech? If so, please describe.
Do others have a difficult time understanding your child's speech? If so, please describe.
Play/Social Skills
Does your child engage in eye contact during play?

YesNoSometimes
Does your child prefer to play alone or with others?

AloneOthers
How does your child interact with others? (shy, aggressive, cooperative, etc)
Does your child greet people arriving or leaving?

yesnosometimes
Does your child engage in turn taking?

yesnosometimes
Does your child initial conversation?

yesnosometimes
What are some of your child's favorite toys/interests/activities?
Education:
Where does the child attend school?
What grade is the child currently in?
Does the child receive any special services at school? (speech, occupational, physical therapy, etc.)
Does the child experience any specific challenges in school? Please describe.
What are the child's strengths at school?
Your Signature Agreeing to Attendance Policy Above
Your Signature Agreeing to Payment Terms Above
I give Milestones Behavior Group consent to assess and treat my child through Occupational Therapy.
How did you receive this form?*

Online, from the websiteEmailed, from Milestones staff
Diagnostic Evaluation Report if applicable

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Insurance will not cover ABA without a formal Autism diagnosis and report. Cancelof
Previous Speech-Langage, Occupational Therapy, Physical Therapy and/or ABA Therapy Reports if applicable

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Other Medical reports if applicable

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For Office Use Only
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Milestones Occupational Therapy Intake Form

Pregnancy and Birth History

Medical History:

Speech and Language Development

Play/Social Skills

Education: