Occupational and Physical Therapy Report for Elks Camp Grassick

Occupational and Physical Therapy Report

for Elks Camp Grassick
To be completed if this individual is receiving or could benefit from occupational and/or physical therapy.
Name of Applicant*

First NameLast Name
Birth Date*

MonthDayYear
Diagnosis:
How does this individual ambulate?*

IndependentlyCrutchesWalkerWheelchair
If this individual uses a wheelchair, how independent is he/she in ADLs, transfers, mobility, etc.?
Does this individual wear orthotic devices?*

YesNo
What type of orthotic devices?
When do they wear their orthotics?

Full timePart timeNight
Occupational Therapist Information
Name of Individual's Occupational Therapist*
Occupational Therapist's Email*
example@example.com
School System or Agency of OT:*
Address of School or Agency*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of School or Agency*
Please enter a valid phone number.
If this individual is accepted, I would like to receive a copy of the report and follow up information after camp:*

YesNo
How would you like to receive information from camp?

I would like to receive paper copies in the mail.I would like to receive digital copies by email.I would like to receive paper and digital copies.
Has this individual ever been evaluated for Occupational Therapy?*

YesNo
Is this individual presently receiving Occupational Therapy services?*

YesNo
How many times a week?
For what length of time?
What areas and/or concerns are being addressed in OT? Please give a brief description of therapy this individual is presently receiving.*
Please indicate specific areas of concentration you would like addressed or certain skills you would like us to work on while this individual is attending camp.*
Please include or attach any other information that you think would be helpful to our staff while working with this individual.
Please upload any pertinent files here.

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Physical Therapist Information
Name of Individual's Physical Therapist
Physical Therapist's Email
example@example.com
School System or Agency of PT:
Address of School or Agency

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of School or Agency
Please enter a valid phone number.
If this individual is accepted, I would like to receive a copy of the report and follow up information after camp:

YesNo
How would you like to receive information from camp?

I would like to receive paper copies in the mail.I would like to receive digital copies by email.I would like to receive paper and digital copies.
Has this individual ever been evaluated for Physical Therapy?

YesNo
Is this individual presently receiving Physical Therapy services?

YesNo
How many times a week?
For what length of time?
What areas and/or concerns are being addressed in PT? Please give a brief description of therapy this individual is presently receiving.
Please indicate specific areas of concentration you would like addressed or certain skills you would like us to work on while this individual is attending camp.
Please include or attach any other information that you think would be helpful to our staff while working with this individual.
Please upload any pertinent files here.

Cancelof
Should be Empty:

Occupational and Physical Therapy Report

Occupational Therapist Information

Physical Therapist Information