Live Oak Kids CA OT Inquiry Form
We look forward to learning more about your child, please complete this form and we will be in touch soon !
Date
-
Month
-
Day
Year
Date
Caregiver Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Current Grade
N/A - At Home with Caregiver
Attends Daycare/Nanny
Preschool
Transitional Kindergarten
Kindergarten
First
Second
Third
Fourth+
Name of School/Daycare
Please share your childs strength, interests and/or favorite things/activities
Please share your reasons for reaching out/areas of concern/ areas of growth you would like to see for your child
Please list any current therapy services your child is receiving (i.e. OT, speech therapy, play therapy, behavioral services, academic support, IEP, IFSP, etc.)
Please list any medical diagnosis or service eligibility categories here
Has your child had an Occupational Therapy Evaluation in the past year ?
Yes
No
If YES- where/with whom did they receive services and for how long
Does your child receive extra support in school
Yes
No
How did you hear about us ?
Google/Internet Search for Occupational Therapy
Google/Internet Search for Nature Programs
Word of mouth/friend
Teacher/school referral or reccomendation
Referral from your medical doctor
Referral from another therapy provider
Facebook Group
Instagram
Other
Reasons for Reaching Out
It was recommended by another professional
My child is struggling at school
My child is struggling at home
We are not happy with the services we are currently receiving
Areas of Concern:
Fine Motor
Visual Motor/Visual Perception
Gross Motor
Sensory Processing
Self-Regulation (managing emotions)
Social Skills
Handwriting
Self Care Skills
Executive Functioning (planning, sequencing, and organizing)
Feeding/Eating
Something Else
If warranted, which setting would you prefer for delivery of Occupational Therapy services ?
At my home
At my child's school
Nature based (at a local park regional park)
Which services are you interested in ? (check all that apply)
Individual OT Servics
Small Group OT Services
School Consultation
Home/Caregiver Consultation
Acorn Adventures Nature Playgroup (ages 1-4)
Sensory Sprouts Enrichment Playgroup (ages 3-6)
Nature Based Therapeutic Summer Camp (ages 4-9)
Other
Would you like to be added to our email list to be notified when priority registration opens for our nature based programs ?
Yes
No
At this time we do not accept insurance. We are an out of network provider. This means we require payment from you at the time of our service. We can provide a superbill which may allow you to get reimbursement from your insurance provider, after the service has been delivered.
No problem. I am ok with this, we would like to continue with services.
I am not able to pay out of pocket. I would like the names of other service providers who may accept insurance.
Please share any other questions, comments, or concerns
Submit
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