Caterpillar Playground Occupational Therapy Intake Form

Occupational Therapy Intake Questionnaire

Evaluation
Hello, and welcome to Caterpillar Playground!
- Completing this intake questionnaire is a requirement before we can schedule your child's evaluation. Our evaluations are currently being scheduled on Wednesdays at 10:00 am or 2:30 pm, Fridays at 10:00 am or 3:30pm. At times, we may be booked out by several weeks. If you are unable to find a time that works for you, please call us so we can try to accommodate your schedule.
- Evaluations include up to two hours 1:1 with you and your child, with a virtual follow-up meeting approximately two weeks later. The total cost is $600. Treatment rate is $180 per clinical treatment hour.
- Please provide all the requested information below to the best of your ability. It helps our therapist be prepared with the best assessment tools for your child.
- When you finish and hit the Submit button, you will be redirected to Theraplatform, which is our scheduling and client portal. You will be prompted to complete account setup at that time, and you will be able to schedule your child's evaluation from the portal.
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Today's date*

MonthDayYear
Date
Parent / Guardian completing form*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason(s) for evaluation:*

Concerns about motor developmentConcerns about sensory integration / regulationConcerns about general developmentConcerns about executive functioningConcerns about developing adaptive / life skillsConcerns about feeding or picky eatingOther
When did you first have these concerns?
What are your primary goals for this evaluation and/or treatment?*
Who can we thank for referring you to Caterpillar Playground?

Who lives with your child most of the time?*

	Name	Age	All the time	Half the time	Less than half the time	Other information
Parent 1
Parent 2
Stepparent 1
Stepparent 2
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Grandmother
Grandfather
Other

Please mark which other interventions or therapies your child has participated in:*

	None	Currently	Past	Report available for review?
Occupational Therapy
Speech therapy
Physical therapy
ABA / Behavior
Psychology
Auditory therapy
Vision therapy
Educational (Regional center/IFSP, IEP, 504)
Play therapy
Other

Does your child attend school?

YesNo
What is the name of your child's school?
What grade level is your child in school?
Is your child in a mainstream ("regular") classroom?
Has your child ever repeated a grade level in school?
What does your child's teacher say about them?
Please describe a typical weekday and a typical weekend day for your child and family.
Medical History

Please share any information that may seem important. If you respond "yes" to these questions, please elaborate.
How does your child usually communicate?*

Gestures (i.e., pointing)Single words or short phrasesScripts, memorized responses, or Gestalt phrasesSpoken language (full sentences)Sounds or approximations of wordsAssisted Augmentative Communication (AAC, such as PECS)Writing or typingCryingOther
What language(s) are spoken in your home?
Please indicate whether your child has any medical diagnoses that may be relevant, such as autism spectrum disorder, Down Syndrome, cerebral palsy, ADHD, etc. *
What was your child's birth weight?*
Was the pregnancy full-term?

Yes, at least 37 weeksNo, preterm delivery
How many weeks of the pregnancy were completed at delivery?
Delivery was:*

Typical / vaginalPlanned CaesarianEmergency CaesarianBreech
Were there any difficulties during pregnancy or delivery?*
Did your child need assistance to begin breathing at birth or have any respiratory, bronchial, cardiac, or lung problems in infancy?*
Were there any other complications or problems after birth or in early infancy?
Were there any difficulties with feeding in early infancy?*
Does your child have any allergies?*
Has your child ever had surgeries, hospitalization, serious illness or injuries?*
Has your child had any diagnostic tests, such as x-ray, EEG, genetic testing, MRI, swallow study, etc.*
Has your child ever had seizures?
Does your child have a history of ear infections? Does your child have tubes?*
Please list any current medications your child is taking.
Does your child use any specialized equipment?
Your child's personality, strengths, and preferences
What are your child's favorite toys or activities?*
What are your child's favorite movies/TV shows, books, or games?
What are your child's favorite characters?
Does your child usually prefer active play or more quiet, seated play?
Does your child usually prefer to play in large groups, or with 1-2 children?
Does your child enjoy imaginary play? If so, what do they like to play?
Does your child have any special interests?*
What activities does your child dislike, refuse, or resist often?*
What do you consider to be your child's strengths?*
In one sentence, how would you describe your child?
Please describe your child's general temperament and energy level as an infant and toddler.
Please describe your child's general temperament and energy level at their current age.
Developmental History and Daily Living Skills

Please answer the following questions about your child. Higher numbers indicate higher agreement with the statement, or more intensity.
My child has difficulty with sleeping.

0

1

2

3

4

5

0 is Less, 5 is More
My child usually chooses one position when sitting on the floor, such as with legs in a "W" shape.*

0

1

2

3

4

5

0 is Less, 5 is More
My child has difficulty with transition times, such as waking up or changing activities.*

0

1

2

3

4

5

0 is Less, 5 is More
My child avoids playing while lying on tummy or used to cry when placed on their tummy to play.*

0

1

2

3

4

5

0 is Less, 5 is More
My child falls often or bumps into things.*

0

1

2

3

4

5

0 is Less, 5 is More
When I hold my child, it seems as if I'm doing all the work, or they are "dead weight".

0

1

2

3

4

5

0 is Less, 5 is More
My child needs to lean against things when sitting.*

0

1

2

3

4

5

0 is Less, 5 is More
My child seems to take unsafe risks, such as walking off of ledges or running into the street.*

0

1

2

3

4

5

0 is Less, 5 is More
My child has been labeled or treated as a "behavior problem".*

0

1

2

3

4

5

0 is Less, 5 is More
My child often watches other children or practices for a long time before attempting new skills.*

0

1

2

3

4

5

0 is Less, 5 is More
My child seems to have difficulty finding an item among other objects, such as a favorite toy in a box, locating their shoes, or their toothbrush among the family's toothbrushes.*

0

1

2

3

4

5

0 is Less, 5 is More
My child spins or hangs upside down.*

0

1

2

3

4

5

0 is Less, 5 is More
My child seeks out messy things, such as playing in soap, lotion, or peanut butter, or saliva.

0

1

2

3

4

5

0 is Less, 5 is More
My child becomes upset when clothing, hands, or face are wet or messy.*

0

1

2

3

4

5

0 is Less, 5 is More
My child hesitates when walking across uneven surfaces or avoids play equipment such as swings.*

0

1

2

3

4

5

0 is Less, 5 is More
My child seems to always need to hold an item in their hands, or they keep their hands up or closed often.*

0

1

2

3

4

5

0 is Less, 5 is More
My child seems to overreact to small bumps or scrapes, crying louder and/or longer than expected.*

0

1

2

3

4

5

0 is Less, 5 is More
My child at times seems to be unaware of things that seem painful, such as hitting their head, injections, falls, or biting.*

0

1

2

3

4

5

0 is Less, 5 is More
My child has difficulty using two hands together, such as clapping, holding paper still while drawing, or catching a ball. *

0

1

2

3

4

5

0 is Less, 5 is More
My child seems to switch from one activity to another very quickly, with short attention.*

0

1

2

3

4

5

0 is Less, 5 is More
My child is slow to attempt challenges or gives up quickly.*

0

1

2

3

4

5

0 is Less, 5 is More
I'm often frustrated because my child doesn't seem to pay attention or stay focused.*

0

1

2

3

4

5

0 is Less, 5 is More

Developmental History (Please answer to the best of your ability)*

	Approximate age	Emerging but not mastered	Never / Not yet	Unsure
Controlling Head
Reaching for object
Rolling both directions
Sitting alone
Finger feeding
Using pincer grasp (thumb and forefinger)
First word
Pointing to pictures or items
Pushing buttons
Following one-step commands
Combining two words
Speaking in sentences
Following multi-step commands
Creeping on hands and knees
Pulling to stand
Taking steps
Eating with a spoon
Drinking from a cup
Drinking from a straw
Walking
Jumping
Scribbling
Drawing a circle
Cutting with scissors
Riding a bike

Did your child gain any skills and then seem to lose them? If yes, please elaborate.
Please select all that apply regarding your child's current feeding skills:*

Holds bottle independentlyFinger feeds self small pieces of foodAccepts food from spoon held by adultFeeds self with spoon with a lot of spillingFeeds self with spoon with little/no spillingUses fork to spear foods and feed selfCuts soft foods with fork and knifeScoops and serves self from large bowlEats a variety of textures and flavorsHas a short list of accepted foods ("picky eater")Eats unusually small amountsTakes unusually small bitesStuffs mouth too fullKeeps pieces of food in mouth for a long time or "pockets" food inside cheeksChews food well before swallowingBites off pieces of foods such as crackers and vegetablesParticipates in family mealsEats a healthy variety of foods (protein, fruits and vegetables, carbohydrates)Gags, coughs, or chokes often when eating or drinkingDrinks from open cup independentlyDrinks from a strawSits in high chair with tray for mealsSits in a chair at table for mealsRemains seated for entire mealsOpens snack packages independentlyInserts straws into drinks independentlyPours liquids with little spillingIndicates when hungryIndicates when fullHelps with meal set up or clean up when askedHelps with food preparation when askedOther
Please list foods that your child is currently able to eat.*
Please elaborate on your child's gagging, coughing, or choking during eating:*
Please select all that apply regarding your child's current dressing skills:*

Removes socks independentlyRemoves shoes independentlyRemoves some loose clothing independentlyRemoves all loose clothing independentlyAssists with dressing by pushing arms/legs throughWears a variety of clothing types and texturesPuts on pants independently (with or without fasteners)Puts on socks independentlyPuts on t-shirt independentlyPuts on jacket independently (with or without fasteners)Puts on shoes independently (with or without tying)Unbuttons large buttons independentlyUnbuttons small buttons independentlyButtons large buttons independentlyButtons small buttons independentlyConnects snaps independentlyZips zippers after connected by adultConnects and zips zippers independentlyTies shoes independentlyOther
Please select all that apply regarding your child's current bathing and hygiene skills:*

Enjoys bath timeCooperates with having face wipedCooperates with bath-time transitionCooperates with washing bodyCooperates with hair washingCooperates with towel dryingWipes nose when promptedWipes nose without promptingWashes and dries hands independentlyWashes body with promptsWashes face independentlyWashes and rinses hair independentlyWashes body independentlyDries self independently with towelOperates faucet and adjusts water temperatureCooperates with toothbrushing performed by adultBrushes teeth with help from caregiverSqueezes toothpaste onto brush independentlyBrushes teeth independentlyCooperates with hair combing/brushingBrushes or combs hair independentlyOther
Please select all that apply regarding your child's current toileting skills:*

Cries or fusses when diaper wet or soiledPoints or gestures to indicate need for diaper changeShows interest or curiosity about potty trainingSits on toilet (child size or adult) for up to one minute supervisedOccasionally urinates into toilet while sitting, may not be intentionalUses toilet for urination with occasional accidents during the dayAvoids using toilet for bowel movementsHistory of constipation or difficulty passing stoolsUsually remains dry at naptimeUsually remains dry overnightCan push pants down for toileting independentlyCan pull up pants independently after toiletingUses toilet independently for both urination and bowel movementsNeeds assistance for wipingWipes independentlyOther

Please indicate ALL availability for treatment sessions. We cannot guarantee availability of your preferred times, but we'll do our best to find a match. Please note, after school times are the most difficult to match due to popularity.*

	Monday	Tuesday	Wednesday	Thursday	Friday
Morning (9-12)
Early Afternoon (12-3)
After School (3-5)

Please add any other information you would like us to know.
Should be Empty:

Occupational Therapy Intake Questionnaire

Medical History

Your child's personality, strengths, and preferences

Developmental History and Daily Living Skills