NAPA Intake Form

Desired Clinic Location*

Program of Interest (click all that apply):*

WeeklyIntensive

How did you hear about NAPA*

Have you completed NAPA intake paperwork previously?*

UPDATE: Has your address changed since filling out previous paperwork?*

UPDATE: Does your child have a new diagnosis?*

UPDATE: Diagnosis*

Other

Parent/Caregiver Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

City / Town / SuburbState / Province

Post Code / Zip CodeCountry

UPDATE: Address

Street Address

Street Address Line 2

City / Town / SubburbState / Province

Post Code / Zip CodeCountry

Country*

Primary Phone Number*

Country CodeArea CodePhone Number

Primary Email Address*

example@example.com

Additional Parent/Caregiver Name

First NameLast Name

Phone Number

Country CodeArea CodePhone Number

Secondary Email Address

example@example.com

Primary Language

Do you have a need for interpretation services?

YesNo

Patient Name*

First NameLast Name

Date of Birth*

Date

Gender

MaleFemalePrefer not to answer

What are some of the cool things your child is good at?

Recognize faces, smile at a familiar song, hold on to favorite objects, be a friend, follow a story, give a hug, swim a lap, etc.

What activities does your child love to do? What motivates your child?

Primary Diagnosis*

While your child may have multiple diagnoses, please choose the diagnosis that best encompasses their presenting symptoms. You may list additional diagnoses below.

Other

Date of Diagnosis

Date

Additional Diagnoses/ Diagnosis Description

My child's diagnosis is considered a progressive or degenerative condition.*

YesNo

My child presents with vision concerns.*

YesNo

If yes, please describe your child's vision concerns.

My child presents with hearing concerns.*

YesNo

If yes, please describe your child's hearing concerns.

My child presents with fatigue concerns.*

YesNo

If yes, please describe your child's fatigue concerns.

History of medical and/or surgical procedures (please list with dates):

History of major hospitalizations/hospitalisations (please list with dates):

UPDATE: Recent Medical History

Current Weight *

Weight Unit*

Kilograms (kgs)Pounds (lbs)

Current Height*

Height Unit*

Centimeters (cm)Inches (in)

Does your child have known allergies?*

YesNo

List allergies and detail allergy management plan:

Does your child have a history of or current seizures?*

YesNo

Are your child's seizures controlled?

YesNo

What might trigger your child's seizure(s)?

How long do your child's seizures typically last?

Describe seizure type(s) and detail seizure management plan:

Does your child have a history of or current heart problems/hypertension?*

YesNo

If yes, please detail more about your child's cardiac history.

Does your child have a history of or current kidney problems?*

YesNo

If yes, please detail more about your child's kidney issues.

Are your child's hips regularly monitored?

YesNo

How often are your child's hips monitored?

Every 6 monthsAnnuallyAs neededOther

When was the date of your child's last hip/pelvic x-ray?

Date

Any history of hip subluxation/dislocation?*

YesNo

Left Hip: Percentage Subluxation

Right Hip: Percentage Subluxation

Has your child now or ever had a diagnosis of decreased bone density?*

YesNo

If yes, please detail more about your child's low bone density.

Has your child now or ever had a diagnosis or concerns of scoliosis?*

YesNo

Scoliosis Degree

Has your child ever had a fracture?*

YesNo

If yes, please describe where the fracture occurred and the cause of the fracture.

My child currently receives (click all that apply):*

My child receives feeding therapy number of visits per Week Month at name of therapy clinic/school .

My child receives occupational therapy number of visits per Week Month at name of therapy clinic/school .

My child receives physio/physical therapy number of visits per Week Month at name of therapy clinic/school .

My child receives speech and language therapy number of visits per Week Month at name of therapy clinic/school .

Please list any other therapies your child participates in, including any other intensive programs.

I would like my child to work on gross motor skills.

YesNo

Gross Motor Skills

	With a lot of help	With a little help	With an assistive device	Independently
Hold their head steady
Roll
Reach
Sit
Crawl
Pull to Stand
Stand
Cruise
Take Steps
Walk
Run/Jump/Hop

Gross Motor Comments and Goals

Include here which adaptive device your child may use as well as goals you would like to work on during the intensive.

I would like my child to work on fine motor, play, and/or self-help skills.

YesNo

Fine Motor/Activity of Daily Living Skills:

	With a lot of help	With a little help	With only one hand	Independently
Hold object with both hands
Hold objects functionally
Brings objects to mouth
Uses utensils for eating
Helps with dressing

Fine Motor/ADL Skills - Comments and Goals

Include here information regarding current fine motor and/or ADL goals.

Sensory Processing/Behavior

	Never	Rarely	Sometimes	Frequently	Always
Difficulty focusing
Demonstrates avoidant behaviors
Demonstrates seeking behaviors
Poor frustration tolerance
Poor emotional regulation
Uses physical means to communicate frustration

When your child gets upset, what helps calm them down?*

Does your child have a behavioral support plan?

YesNo

Would you like to upload the behavioral support plan now?

YesNo

Behavioral Support Plan

Please briefly describe your child's behavioral support plan.

Sensory Processing - Comments and Concerns.

Include here any information that may be helpful for us to better support your child's sensory needs. Please detail any goals that pertain to sensory processing.

Which area would you prefer to focus on during speech therapy sessions? .*

(Please note, English is the primary language of our speech therapists and may limit their ability to effectively deliver speech services to non-English speaking clients. Please inquire if you have questions.)

Speech and Language Skills

	Never	Rarely	Sometimes	Frequently	Always	Not Applicable
Vocalizes
Babbles
Follows simple commands
Vocalizes/vocalises single words
Vocalizes/vocalises 2-3 word utterances
Speech production/ articulation is hard to understand
Uses a low tech device for speech and language (PECS, board, book, etc)
Uses an electronic device for communication (Proloquo, LAMP, etc)
My child understands much more than they are able to communicate.

My child uses the following to communicate (check all that apply):

Speech & Language Skills - Comments and Goals (if relevant, please include the name of your child's AAC device and current access methods).

Include here information about which device your child may use, their current ability with a device, and goals you would like to work on during the intensive.

I am interested in a feeding-focused intensive. This includes forgoing some motor-based hours so that we may increase the number of feeding therapy hours.*

YesNo

Feeding History (please check all that apply):

Is tube fed (G, NG, GJ, J tubes)Difficulty swallowing (chokes, coughs, has a diagnosis of dysphasia)Difficulty gaining weight/Doctors are concerned with child's weightHas sensory-based feeding challenges (ie sensitive to texture, temperature, look, smell)Requires adapted seating during mealtimesMealtimes are stressful for child and/or caregiver

Does your child present any of these mealtime behaviors?

Refuses to eat certain types of foodHas a poor appetiteTantrums during mealtimesLeaves the table during mealtimesRefuses bites offeredGags or vomits during oral meals and/or tube feeds

Feeding Skills

	Is able	A little hard	Very Hard	Unable
Manages secretions with swallowing
Swallows liquids (from a cup, bottle or straw)
Eats solid foods by mouth (including purees)
Eats enough food by mouth
Is able to manage age appropriate food textures
Has an age appropriate and varied diet

Who feeds your child?

Who else is able to feed your child?

How do you know when your child is hungry?

How do you know when your child is all done eating?

How long does a meal typically last for you child?

Where does your child sit for mealtimes?

How much food does your child finish in a typical meal?

Does your child tolerate messy or food play?

Describe your child's diet

Age appropriateLimited textures (i.e crunchy or purees only)Limited food repertoire (ie picky, fewer than 30 foods)Other

What techniques have you used to support your child in eating? What has worked? What has not worked?

Feeding History & Skills - Comments and Goals:

Monday