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 name:
First Name
Last Name
Parent email:
example@example.com
Parent Phone:
Please enter a valid phone number.
Parent 2 name: (if applicable)
First Name
Last Name
Parent email:
example@example.com
Parent phone:
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If separated, divorced or foster- who has legal custody?
Person filling out this form:
Date form completed:
-
Month
-
Day
Year
Date
Preferred method of contact:
Phone
Email
Insurance provider:
Do you have a written prescription?
Name of MD or referral source:
What services are you interested in?
Occupational Therapy
Physical Therapy
Preferred times- Mondays
Unavailable
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Preferred times- Tuesdays
Unavailable
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Preferred times- Wednesdays
Unavailable
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Preferred times- Thursdays
Unavailable
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Preferred times- Fridays
Unavailable
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Other scheduling comments:
Back
Next
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).
Is there a family history of the following?
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
Language(s) spoken at home:
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, strength and favorite things/activities:
Back
Next
IV. Educational History
Name of 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
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
Other:
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:
Back
Next
VII. Other Pertinent Medical History
Pediatrician's name:
Please list other specialist(s) (Medical, physcological) working with your child:
Please list your child's diagnosis(es), if applicable:
Please list current medications:
Please list any allergies:
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:
Back
Next
VIII. Developmental History
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?
Back
Next
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:
Back
Next
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
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:
Back
Next
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 see your child achieve through therapy:
1)
2)
3)
Submit
Should be Empty: