Occupational Therapy Intake Form

Occupational Therapy Intake Form

Pediatric Therapy Bridge
Full Names of Guardians:

Guardian 1Guardian 2
Contact Number for Guardian 1
Format: (000) 000-0000.
Contact Number for Guardian 2
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Email
example@example.com
Would you like us to communicate with you via email and text message?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Full Name:

First NameLast Name
Date of Birth:
Gender?
Name of Physician?
Name of School and Grade?
Please list Child's siblings and birth order
Birth History
Was your child born full term?
Child's birth weight?
Complications during pregnancy or at birth? Please comment
Difficulties feeding as a newborn? Bottle or breast fed?
Medications?
Hospitalizations?
Allergies?
Diagnoses?
Current or Past Therapies?
Please email all previous therapy evaluations or relevant history to Pediatrictherapybridge@gmail.com
Specialists?
Please provide additional information regarding your child's past medical history, interventions, and therapies.
Developmental Milestones

At What Age Did Your Child...
Sit Independently
Crawl
Walk
Speak First Words
Finger Feed Self First Foods
Please describe any delays or concerns your child had with these milestones:
Parental Concerns

Please Describe
Fine Motor Concerns? Y or N, please comment
Eating Concerns? Please describe Y or N, please comment What does your child eat? What does your child refuse to eat? When did the concerns begin?
Sensory Concerns? Y or N, please comment
Behavioral Concerns? Y or N, Please comment
Gross Motor Concerns? Y or N, please comment
Coordination Concerns? Y or N, please comment
What is your child's sleeping habits? Please describe
School Concerns? Y or N, please comment
Please share your child's strengths and weaknesses...
Thank you for your information. We look forward to working with your child! -Pediatric Therapy Bridge
Should be Empty:

Occupational Therapy Intake Form

Birth History

Developmental Milestones

Parental Concerns

Thank you for your information. We look forward to working with your child! -Pediatric Therapy Bridge