Intensive Program Intake Paperwork
Please complete the information requested below.
TES Location
Please Select
Los Angeles, CA
Troy, MI
Parent/Caregiver Information
Name of Person Completing this Form
First Name
Last Name
Relationship to Child
Email
example@example.com
Phone Number
Please enter a valid phone number.
Child's Information
Child's First Name
Child's Last Name
Preferred Name:
Date of Birth:
-
Month
-
Day
Year
Date
Sex:
Gender identity:
Medical Diagnosis:
Date diagnosis was given (estimate):
-
Month
-
Day
Year
Date
Diagnosis Description:
Current Medications:
Does your child have any known allergies?
No
Yes
Please describe allergies:
Who does your child live with?
Who is the primary caregiver?
List additional caregivers such as grandparents, extended family, nurse, nanny, etc.:
Medical History
Pregnancy History (if known):
Birth History (if known):
Child's gestational age in weeks:
History of any medical/surgical procedures. Include year/dates if known:
*
Major hospitalizations. Include reason and year/date:
*
Is your child followed by an orthopedic physician or other specialist to monitor hip alignment?
No
Yes
When was the last x-ray?
How often are they monitored?
Results of hip x-rays:
both dislocated
L dislocated
R dislocated
both subluxed
L subluxed
R subluxed
no concerns
Upload hip radiology reports
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History of diagnosis of decreased bone density?
No
Yes
If yes, please explain
History or concern of scoliosis?
No
Yes
Degree of curvature
History of kidney problems?
No
Yes
If yes, please explain:
History of heart problems/surgeries?
No
Yes
If yes, please explain:
History of seizures?
No
Yes
If yes, please explain:
Vision concerns?
No
Yes
If yes, please explain:
Hearing concerns?
No
Yes
If yes, please explain:
Endurance/respiratory concerns?
No
Yes
If yes, please explain:
Tracheostomy?
No
Yes
G-tube/PEG tube?
No
Yes
Physical Abilities
Describe your child’s gross motor abilities
Can your childindependently perform the following skills?
No
Yes
Describe
Hold their head steady
Roll from stomach to back
Roll from back to stomach
Sit
Crawl (army crawl or hands and knees crawling)
Pull to stand
Stand
Cruise
Walk
Run/jump/skip/walk up and down stairs
Describe the goals you would like your child to achieve during their intensive therapy session.
Fine Motor - Is your child Is your child independently able to:
No
Yes
Describe
Grasp objects in both hands?
Hold onto objects and use functionally?
Brings objects to midline or mouth?
Finger feed?
Use cutlery to feed self?
Hold a pencil or crayon?
Does your child display any sensory avoidances or seeking behaviors (textures, sounds, movement, tastes, smells)?
No
Yes
If yes, please explain:
Please check part(s) of the body your child can use purposefully:
Right Hand
Right Arm
Right Foot
Right Leg
Left Hand
Left Arm
Left Foot
Left Leg
Other
Behavior
what is motivating for your child?
ex. music, TV shows/movies, games/toys, drinks/food, people, activities/hobbies/sports, etc.
Does your child make good eye contact?
No
Yes
Does your child easily startle?
No
Yes
If yes, what causes the startle?
Does your child repeat sounds, words, or phrases over and over?
No
Yes
Can your child follow simple directions ("look at the picture," "shut the door," or "get your shoes.")?
No
Yes
Is your child willing to try new activities?
No
Yes
Can your child play for a reasonable length of time?
No
Yes
With assistance or alone?
Assistance
Alone
Please describe behavior goals:
Submit
Should be Empty: