Intake Form

OT Client Intake Form
Today's Date*

MonthDayYear
Date
Personal Information
Child's Legal Name*
Date of Birth *

MonthDayYear
Date
Age*
Gender*

MaleFemale
Medical Diagnosis *
If applicable. If not, please put N/A
Current Medications *
Allergies *
Legal Guardian *
Phone Number*
Please enter a valid phone number.
Email Address *
Preferred contact method*

EmailCallTextOther
Legal Guardian
Phone Number
Please enter a valid phone number.
Email Address
Preferred contact method

EmailCallTextOther
Person filling out form and relationship to child*
If someone other than the individuals listed above will be bringing the child or with the child during their therapy time, please provide their name and phone number.
e.g., grandparents, nanny, sibling, etc.
Home Address*

STREET ADDRESS

STREET ADDRESS LINE 2

CITYSTATE / PROVINCE

POSTAL / ZIP CODE
How did you hear about us?*
Primary Care Physician*
Physician's Phone Number*
Please enter a valid phone number.
Physician's Fax Number
Please enter a valid phone number.
Insurance Information
Primary Insurance*
Please list name as read on insurance card
Policy Holder*
Member ID#*
Group Number *
If applicable, if not put NA
Secondary Insurance
Please list name as read on insurance card
Member ID#
Group Number
If applicable, if not put NA
Background Information
General History
What are your current concerns for your child?*
What are your primary goals for therapy?*
Has your child received occupational, physical, and/or speech therapy before? *
Pregnancy & Delivery
Did the child's mother have any illnesses or complications during pregnancy or delivery?*
Was your child premature?*
please include gestational age child was born and their birth weight
Did your child require any medical procedures before, during, or after birth?*
please describe and list approximate dates
Developmental History
Please indicate at what age each major milestone was reached:

Sitting Independently blank*
Rolling blank*
Crawling blank*
Walkingblank*
Talking blank*
Medical History
Please describe illnesses, hospitalizations, or surgeries that your child has had and/or any upcoming procedures*
Please be specific and include approximate dates
Has your child had a neuropsychological evaluation?*

YesNo
Vision Status*
If your child has a visual impairment, please elaborate
(e.g., cortical vision impairment, wears glasses, etc.)
Hearing Status*
If your child has a hearing impairment, please elaborate
(e.g., mild, moderate, severe, unilateral/bilateral, hearing aids, cochlear implants, etc.)
Does your child use adaptive equipment?*

YesNo
If yes, please list the adaptive equipment they use
(e.g., manual wheelchair, power wheelchair, communication device, orthotics/splints, gait trainer/walker, etc.)
Social History & Living Situation
Please describe your child's living situation *
Who lives in the home? Any recent changes?
Languages spoke in the home*
Siblings' names and ages*
If applicable, if not put NA
Educational History
Is your child in school?*

YesNo
If yes, please elaborate. If no, does your child attend play dates or other group activities with peers?
grade, name of school, teacher, type of classroom (general education and/or special education, IEP, does your child receive services, etc.
Does your child face behavior or academic challenges at school?
Handwriting, communication, transitioning from task, sharing toys, reading, etc.
Personal Information
Please describe your child's personality *
How does your child handle changes and variation in their daily routine?*
Does your child have tantrums?*
What games, activities, toys, and/or books does your child enjoy?*
Does your child have any strong dislikes?*
Describe how your child interacts with other children*
Daily Routines: please comment on your child's habits, challenges, concerns, and levels of independence for the following areas:
Feeding/Eating*
utensil use, preparing simple meals, etc.
Dressing*
getting dressed/undressing, manipulating fasteners (buttons, zippers, etc.), tying shoes, picking out weather appropriate clothing
Hygiene*
brushing teeth, combing/brushing hair, bathing, washing hands, etc.
Toileting*
identifies need to use bathroom, wipes self, etc.
Sleep*
has trouble falling asleep, wakes up in middle of the night, etc.
Safety Awareness*
runs away from you, may touch stove, unaware of people around, etc.
Briefly describe a typical day for your family, especially this child.*
Does your child experience difficulties with any part of their daily routine?
Please provide your availability for scheduling therapy sessions*
Monday, Tuesday, Wednesday, Thursday, Friday? Morning or Afternoon?
Please share any additional information that you feel would be helpful for us to know.
Should be Empty:

OT Client Intake Form

Personal Information

Insurance Information

Background Information