Initial Intake Form
Kia Kaha Therapy
Parent/Caregiver Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Additional Parent/Caregiver Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
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
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
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
*
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:
*
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: