Consultation Assessment Form
Before we begin, I would like to gather some information from you that will allow me to maximize our time together in the discovery call to determine if my services are a good fit for your needs.
Demographic Information:
Caregiver Full Name (who is filling this form out)
*
First Name
Last Name
Caregiver's Email
*
example@example.com
Child's Name (first is fine)
First Name
Last Name
Child's Gender:
Child's Age:
State of Residence:
My child has a diagnosis or specific area of concern that has been identified by myself or our medical care provider.
Yes
No
If yes, please explain:
Our experience with Occupational Therapy (OT)
Someone said it might be helpful so I’m searching for more information
Our medical provider has recommended this service and we are waiting to get in for a clinic appointment
My child has graduated from therapy services and I need help figuring out what to do at home
We are currently enrolled in OT (school or clinic based) and are looking for more specific programming or assistance at home.
I already have an idea about what to do for my child’s needs and just need help figuring out how to implement it.
True
False
I am open to completing digital coursework, following the programming, and meeting on a weekly or monthly basis to make progress with my child in the area of concern.
True
False
I am interested in connecting with others who have similar issues.
True
False
Please check all that apply for areas of concern for you or your child:
Feeding (amount, variety, bottling, transition to foods, g-tube)
Sensory Processing (sensitivity, over-responsive, under-responsive, avoiding certain types of sensory input that can include touch, sound, etc)
Emotional and behavioral regulation (ability to match response to the situation)
Reflex Integration
Modification to home programming I already have
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