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New Patient Intake Form
Thank you for your interest in our clinical services. To help us better serve you, please provide us with the information requested below. Please be assured that this information will be held confidential, and is necessary for the RPTA staff to determine the most appropriate evaluation and therapy services. A copy of our Notice of Privacy Practices is also available upon request.
I. General Information
Child's name
*
First Name
Last Name
Child's date of birth
*
-
Month
-
Day
Year
Date
Parent completing form:
*
First Name
Last Name
Parent email:
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Parent Phone:
*
Please enter a valid phone number.
Parent 2 name: (if applicable)
First Name
Last Name
Parent 2 phone:
Please enter a valid phone number.
If separated, divorced or foster- who has legal custody?
Date form completed:
-
Month
-
Day
Year
Date
Insurance provider:
*
Insurance member ID number:
*
Do you have a written prescription? (One will be needed if using insurance or attempting reimbursement.)
*
Name of MD or referral source:
*
What services are you interested in?
*
Occupational Therapy
Physical Therapy
Preferred times- Mondays
*
Open
Unavailable
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Preferred times- Tuesdays
*
Open
Unavailable
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Preferred times- Wednesdays
*
Open
Unavailable
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Preferred times- Thursdays
*
Open
Unavailable
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Preferred times- Fridays
*
Open
Unavailable
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Other scheduling comments: i.e. open availability, flexible schedule, etc.
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Primary concerns: Please describe what brings you here.
*
II. Family History
Who lives in the child's household? Please include relationship and age of any sibling(s).
Language(s) spoken at home:
Is there a family history of the following?
Maternal
Paternal
Learning Difficulties (reading, math, writing, spelling)
Speech or Language problem (articulation, stuttering, etc.)
Developmental Disorder (such as Autism, Asperger’s disorder, etc.)
Psychological/Emotional Disorders (depression, excessive anxiety, mood swings, OCD, etc.)
Cognitive Disorder (Intellectual disability, Attention-deficit, etc)
Addiction
Please describe after school child care, dual household arrangements, or other pertinent living situations:
III. Child's Social History
Please list sports or other organized extra-curricular activities/classes the child attends:
Please provide a snapshot of the child's personality, strengths and favorite things/activities:
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IV. Educational History
Name of current school:
*
Grade:
Days/hours attending:
*
Does your child have an IEP? If yes, please list services offered:
*
V. Therapy History
Has your child received services in the past?
*
No
Occupational
Physical
Please list which services your child is currently receiving and for how long they have been seen there:
Has an assessment been completed in the last 6 months?
*
No
Yes
VI. Birth History
Is your relationship to the child:
*
Biological
Adopted
Legal Guardianship
If other, please explain:
Weeks gestation:
Delivery:
Vaginal
C-section
Weight at birth:
Length at birth:
APGAR scores:
Passed newborn hearing screen:
No
Yes
Mother's pregnancy:
*
No complications
Blackouts
Falls/Injury
Excessive bleeding
Hypertension
Diabetes
Emotional stress
Toxemia
Alcohol/drug use
Tobbacco use
Child's delivery:
*
No complications
Induced labor
C-section
Breech birth
Labor >12hrs
Early term
Premature
Overdue
Other:
Child's condition at birth:
*
Typical
Lack of oxygen
Breathing problem
Birth injury/defect
Jaundice
ICU
Explanations:
Were there any feeding or weight gain issues?
Was your child particularly difficult to console when agitated?
Please briefly describe your child's sleep patterns and activity levels as an infant:
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VII. Other Pertinent Medical History
Pediatrician's name:
*
Please list other specialist(s) (Medical, psychological) working with your child:
Please list your child's diagnosis(es), date of each diagnosis and who diagnosed them, if applicable:
Please list any allergies:
Please list current medications:
Do any of the following apply to your child?
Chronic ear infections
Ear tubes
Hearing problems
Vision problems
Glasses
Respiratory issues
Cardiac issues
Orthopedic issues
Reflux
Feeding tube
Genetic disorder
Seizures
Head injury
Other:
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VIII. Developmental History
You may record here any previous developmental concerns, hospitalizations, or other events that have occurred.
Infancy/toddler:
Preschool:
Elementary school:
IX. Current Skills
-Sensory Processing
Does your child display sensitivity to sensory input (e.g. movement, sounds, touch, taste, smell)Please give specific examples:
Does your child seem to seek or crave certain types of sensory input (e.g. jumping a lot, frequently spinning, often fidgeting with hands, mouthing objects, messy play).
Does your child require more time than other children to process information (respond to your questions, register pain, etc.)
How does your child tolerate group situations (playing with others on playground, working with peers in school, family gatherings)?
How does your child tolerate errands outside the home?
How does child tolerate restaurants or other outings?
Does child hyper-focus on certain activities?
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Sensorymotor
N/A
Seldom
Sometimes
Often
Child seems ‘floppy’ when holding him/her
Needs more support than peers to sit upright
Slouches/slumps in seats
Prefers to lie on floor to play
Difficulty initiating or copying movements
Awkward gait pattern (floppy, Stiff, on toes, etc)
Difficulty coordinating left/right sides
Clumsy / bumps into objects / trips easily
Poor strength
Seems fearful of movement
Unusual pencil grip-immature/tight/weak
Switches hands frequently
Increased/decreased pressure on writing tools
Difficulty coordinating left and right hands
Motor Planning
N/A
Seldom
Sometimes
Often
Plays with the same toys or in the same way, difficulty being flexible or creative.
Unable to remember sequences of steps for motor tasks from one day to the next
Difficulty imitating motor tasks from a given demonstration (verbal and visual)
Visual Perception
N/A
Seldom
Sometimes
Often
Difficulty completing puzzles
Poor spatial relations/concepts (i.e. big-small, under-over, front-behind)
Unable to copy from blackboard or loses place
Reverses letters in writing (over 7 years old)
Other sensory concerns:
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Behavior
N/A
Seldom
Sometimes
Often
Becomes easily frustrated
Impulsive
Annoys / distracts others frequently
Verbally / physically aggressive
Cannot tolerate changes in routine
Unable to attend to age appropriate tasks
Prefers to play alone
Follows your directions
Inflexibility with change
Other behavioral or social concerns:
Gross motor skills
Unable to perform task
Task skill emerging
Can perform task proficiently
Is this a concern?
Roll
Sit without support
Crawl on hands and knees
Stand unsupported
Walk unaided
Jump with both feet
Run
Catch a ball with two hands
Catch a ball with one hand
Throw a ball with one hand
Climb a play structure
Ride a trike
Ride a bike
Stand on one foot
Walk on a curb/uneven surface
Jumping Jacks
Pump legs to swing
Other gross motor concerns:
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Fine motor skills
Unable to perform task
Task skill emerging
Can perform task proficiently
Is this a concern?
Shows a hand preference
Pick up a Cheerio between index and thumb fingers
Self feed with a spoon
Use scissors
Build with age-appropriate blocks or Legos
String beads
Draw a straight line
Copy simple shapes
Write legibly for age
Open/close containers
Other fine motor concerns:
Self-help skills
Unable to perform task
Task skill emerging
Can perform task proficiently
Is this a concern?
Undress self
Dress self
Manage buttons or snaps on clothes
Orient clothing independently
Ties shoes
Unzip and load zipper independently
Buckle/unbuckle a belt
Feed self with utensils
Drink for an open top cup
Use a toilet independently
Put toys away
Complete familiar morning routines
Complete familiar routines for getting ready for bed
Please list any chores/responsibilities your child has at home:
Please list any other self-help concerns:
Please list three goals you would like to help your child achieve through therapy: 1)
*
2)
*
3)
*
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