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 Fridays at 10:30 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 $700. Treatment rate is $220 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
2 digit month, 2 digit day, 4 digit yearDate
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian completing form

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason(s) for evaluation:

Other
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?

Rows	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:

Rows	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?
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?

Other
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?
How many weeks of the pregnancy were completed at delivery?
Delivery was:
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

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

Rows	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

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

Rows	Never	1	2	3	4	5
My child has difficulty with sleeping.
My child usually chooses one position when sitting on the floor, such as with legs in a "W" shape.
My child has difficulty with transition times, such as waking up or changing activities.
My child avoids playing while lying on tummy or used to cry when placed on their tummy to play.
My child falls often or bumps into things.
When I hold my child, it seems as if I'm doing all the work, or they are "dead weight".
My child needs to lean against things when sitting.
My child seems to take unsafe risks, such as walking off of ledges or running into the street.
My child has been labeled or treated as a "behavior problem".
My child often watches other children or practices for a long time before attempting new skills.
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.
My child spins or hangs upside down.
My child seeks out messy things, such as playing in soap, lotion, or peanut butter, or saliva.
My child becomes upset when clothing, hands, or face are wet or messy.
My child hesitates when walking across uneven surfaces or avoids play equipment such as swings.
My child seems to always need to hold an item in their hands, or they keep their hands up or closed often.
My child seems to overreact to small bumps or scrapes, crying louder and/or longer than expected.
My child at times seems to be unaware of things that seem painful, such as hitting their head, injections, falls, or biting.
My child has difficulty using two hands together, such as clapping, holding paper still while drawing, or catching a ball.
My child seems to switch from one activity to another very quickly, with short attention.
My child is slow to attempt challenges or gives up quickly.
I'm often frustrated because my child doesn't seem to pay attention or stay focused.

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
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:

Other
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:

Other
Please select all that apply regarding your child's current bathing and hygiene skills:

Other
Please select all that apply regarding your child's current toileting skills:

Other

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.

Rows	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