Initial Intake Form
Kia Kaha Therapy
Parent/Caregiver Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Additional Parent/Caregiver Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Details
*
First Name
Last Name
Date of Birth
*
Please select a day
1
2
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5
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Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
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1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
Male
Female
Prefer not to answer
Tell us about your Child.
What are some of the cool things your child is good at?
What activities does your child love to do? What motivates your child?
Medical History
Primary Diagnosis
Other
Date of Diagnosis
-
Month
-
Day
Year
Date
Additional Diagnoses/ Diagnosis Description
My child's diagnosis is considered a progressive or degenerative condition.
*
Yes
No
My child presents with fatigue concerns
*
Yes
No
History of medical and/or surgical procedures (please list with dates):
*
History of major hospitalisations (please list with dates):
*
Current weight (in kg)
*
Current height (in cm)
*
Does your child have known allergies?
Yes
No
List allergies and detail allergy management plan:
Does your child have a history of or current seizures? *
*
Yes
No
Are your child's seizures controlled?
Yes
No
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?
Yes
No
Has your child now or ever had a diagnosis of decreased bone density?
Yes
No
Are your child's hips regularly monitored?
Yes
No
Other
Any history of hip subluxation/dislocation?
Yes
No
Developmental Skills
I would like my child to work on gross motor skills.
Yes
No
Gross Motor Skills
*
Rows
With an assistive device
With a lot of help
With a little help
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.
I would like my child to work on fine motor, play, and/or self-help skills.
Yes
No
Fine Motor/Activity of Daily Living Skills:
*
Rows
With only one hand
With a lot of help
With a little help
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
When your child gets upset, what helps calm them down?
Are there any additional reports, evaluations, or documents that you would like to provide at this time?
I give permission for my child to be filmed and photographed to be used as part of his/her assessment plan/individual plan (centre use only)
*
Please Select
Yes
No
I give permission for my child to be filmed and photographed to be used on Kia Kaha’s Website/Facebook page/Instagram Page/Pamphlet
*
Please Select
Yes
No
Submit
Should be Empty: