• DEVELOPMENTAL SUMMARY

  • What evaluations are your child scheduled to receive? (please be sure to check all that apply)*

  • REASON FOR SEEKING SERVICES

  • Occupational Therapy

  • Physical Therapy

  • Speech and Language Therapy

  • Feeding Therapy

  • Infant Feeding

  • Please check off all areas of concern that apply*

  • Orofacial Myofunctional

  • Please check off all areas of concern that apply*

  • BIRTH AND MEDICAL HISTORY

  • Was your child born premature or full-term?*
  • Multiple births?*

  • Did your child spend any time in the NICU?*
  • My child has a history of... (please check all that apply)

  • Medical history related to orofacial development
  • Please select any assistive devices that your child uses (if applicable)*

  • DEVELOPMENTAL MILESTONES

  • Did your child meet their developmental milestones on time? (i.e., rolling, sitting up, crawling, standing, walking, talking, etc.)*
  • Please indicate the approximate age at which your child met the motor milestones below:*
  • Current level of mobility (please check all that apply)*
  • Support required with crawling*
  • Support required with walking*
  • Support required with stairs*
  • Support required with walker*
  • Support required with wheelchair*
  • Support required with crutches*
  • Support required with gait trainer*
  • Please indicate the approximate age at which your child met the speech/language milestones below: (if applicable)
  • Developmental milestones have been...*

  • Other

  • Does your child have an established dominant hand?*

  • Please note that our evaluations will be completed in English. If you are seeking a bilingual language evaluation, please call for resources. 

  • SELF-CARE SKILLS

  • Please indicate how much help your child needs with the following routines:

    • Dependent: I do 100% of this task for my child
    • A lot of help: My child participates, but I help with 50% or more
    • A little help: My child can do this with reminders or minimal help
    • Independent: My child does this task 100% on their own

  • Bathroom

  • Toileting accidents currently?*
  • Can wipe after toileting and manages clothing:*
  • Does your child experience any of the following? (please check all that apply)

  • Grooming

  • Wash hands:*
  • Wash face:*
  • Brush/comb hair:*
  • Brush teeth:*
  • Tolerates haircuts and nail clipping:*

  • Bathing

  • Wash hair:*
  • Wash body:*

  • Dressing

  • Ability to undress self:*
  • Put on a top (short sleeve, long sleeve, hoodie, etc.)*
  • Put on bottoms (jeans, sweatpants, etc.)*
  • Put on socks*
  • Put on shoes*
  • My child is able to manage the following fasteners independently:*

  • Feeding

  • Use a fork*
  • Use a spoon*
  • Use a knife to spread or cut*
  • Drink from an open cup*

  • Sleep

  • Falls asleep independently?*
  • Stays asleep overnight?*
  • Sleeps in their own bed/room?*

  • SOCIAL EMOTIONAL OBSERVATIONS

  • Do you have concerns with your child’s social-emotional development? Please check all that apply:

  • How often do self-regulation challenges occur?*
  • When upset, how long does it take for your child to calm?*
  • What do self-regulation challenges look like for your child? Please check all that apply:*

  • What calming/coping strategies have you tried?
  • Are there any specific triggers for self-regulation challenges? If so, please explain:

  • CURRENT SPEECH AND LANGUAGE SKILLS

    Please check all that apply.
  • Receptive language (understanding):*
  • Expressive language (use):*
  • Child's primary mode of communication:*
  • Child's language processing style (if known)
  • Social language/ play skills:*
  • Social communication (check all that apply):*
  • Play (check all that apply)*

  • FEEDING OBSERVATIONS

  • GI: (please check all that apply)*
  • Respiratory: (please check all that apply)*
  • Behaviors observed during feeding: (please check all that apply)*
  • Please check the methods of consumption your child has used/currently using:*
  • Please check the methods of consumption your child has used/currently using:*
  • Check All That Apply*

  • BREAKFAST

  • LUNCH

  • DINNER

  • SNACKS

  • Rigo Concept Based on Schroth Method 

  • AAC Evaluation Questions

  • What modes of communication does your child utilize? (please check all that apply)
  • Does your child currently have an AAC system (e.g. visual supports, high-tech speech generating device, etc.)
  • Did your child have any other previous AAC use?
  • My child... (please check all that apply)
  • How well is your child understood by varied communication partners?
    Rows

  • Aquatic Therapy Questions

  • Will your child benefit from a chair lift to enter/exit the pool?*
  • Please describe your child's toileting needs (please check all that apply)*
  • Is your child independent in shallow water?*
  • Is your child independent in deep water?*
  • Is your child afraid of water?*
  • Contraindications: Aquatic therapy may be contraindicated for individuals with the conditions listed below. Please check all that apply to your child and know that upon your land-based assessment, the therapist will ask for clarification to determine appropriateness of aquatic therapy for your child.*
  • Precautions: Please check all that apply to your child and know that upon your land-based assessment, the therapist will ask for clarification to determine appropriateness of aquatic therapy for your child.*

  • Orofacial Myofunctional Observations

  • Oral Habits (please check all that apply)*

  • Rest Posture/Function

  • Does your child's mouth usually remain:*
  • Where does your child's tongue usually rest?*
  • My child (please check all that apply)*

  • Swallowing:

  • My child (please check all that apply)*

  • Additional Infant Questions

  • Current sleep routine (please check all that apply)*

  • GI observations (please check all that apply)*

  • Respiratory observations (please check all that apply)*
  • Has your child started solids?*
  • Behaviors observed during feeding (please check all that apply)*
  • Please check the methods of consuption your child has used or is currently using*

  • What are your family's main goals as related to treatment? (please check all that apply)*
  • Should be Empty: