INTAKE FORM

INTAKE FORM
2653 Canton Road, Marietta, GA 30066 929-496-6435 I AllofTOT@gmail.com I www.all-of-t.com
Childs Full Name
Date of Birth

MonthDayYear
Date
Other names
Age
Address
Parent/Guardian Name(s): Phone Number(s):
Parent/Guardian

First NameLast Name
Email for #1
example@example.com
Phone Number for #1
Please enter a valid phone number.
Parent/Guardian

First NameLast Name
Email for Parent #2
example@example.com
Phone Number #2
Please enter a valid phone number.
SECTION 2: REFERRAL & DOCTOR INFORMATION
Referring Provider
Your Child's Physician's office address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring Provider: Pediatrician / Primary Care Physician: Phone Number
Fax number
Please enter a valid phone number.
Pediatrician Primary Care Physician
Reason for Referral
SECTION 3: INSURANCE INFORMATION
Primary Insurance Company: Member ID #:
Primary Insurance Company
Member ID
Group
Policy Holders Name
DOB
Relationship to Child
Employer
Secondary Insurance if any
Policy #2 Member ID
Policy #2 Group Member Name and Number
DEVELOPMENTAL HISTORY & MILESTONES
Demographics: Who does your child live with?
medical history/family history/ear infections/surgeries
Current/Past therapies
Siblings? Any siblings with a diagnosis?
Is your child a picky eater?
Strengths interests motivators
Developmental Milestones checklist

Walks and runs without frequent fallsClimbs stairs with alternating feetJumps with two feetThrows a ball forwardDemonstrates body awareness during movementtUses pincer grasp (thumb and index finger)Holds crayons/markers with controlUses tools (spoon, tongs, scissors)Copies basic shapes (line, circle, cross)Manipulates small objects without droppingOther
If there are areas that haven't been met, please feel free to list them here.
Home routines/behavior at home and in the community
Community participation (outside of therapy, play dates, extracurricular activities)
School/Grade
School location
Does your child have an IEP?
Any classroom concerns
SENSORY PROCESSING & REGULATION

Auditory, Tactile, visual, oral, self regulation

	Yes	Sometimes	Not yet
Tolerates different textures (clothing, play materials)
Seeks movement appropriately
Calms with deep pressure or movement
Tolerates loud or unexpected sounds
Maintains regulation during transitions
Tolerates messy play (paint, sand, slime, food textures)
Does not avoid grooming (hair brushing, face wiping)
Explores objects with hands appropriately
Avoids excessive touching of others or objects
Seeks deep pressure appropriately
Calms with heavy work (pushing, pulling, carrying)
Maintains personal space during activities
Tolerates swinging, spinning, or movement
Demonstrates balance during movement
Does not become overly dysregulated with movemen
Transitions from movement to seated tasks
Seeks movement in a safe, functional manner
Tolerates everyday sounds
Responds appropriately to name
Follows verbal directions despite background noise
Does not cover ears or flee from sound
Maintains regulation in noisy environments
Tracks moving objects
Tolerates visually busy environments
Maintains visual focus without distraction
Tolerates a variety of food textures
Does not mouth non-food objects
Seeks oral input appropriately (chewy foods, straws)
Accepts tooth brushing
Responds to co-regulation from adults
Regulates arousal level for learning
Uses sensory strategies when upset

Self Care and ADL skills

	Yes	No	Sometimes
Feeds self using utensils
Tolerates tooth brushing
Assists with dressing tasks
Dresses upper body
Dresses Lower Body
Toileting awareness
Wipes self, completes toileting hygiene

Preferred site for OT visits

ABA CLINICS (Blue Sprig, Harmony Behavior)Canton Road OfficeSchool(Preschool, separate travel fee billed outside of insurance)
SECTION 8: SCHEDULING & LOCATION Preferred Days: Mon Tues Wed Thurs Fri Sat Preferred Time: Morning Afternoon Evening Can travel to 2653 Canton Road office? Yes No Sometimes
Other preferences home school telehealth
File Upload (here is where you can upload copies of your insurance, any past reports, or forms with Past Medical History or Past Evaluations.

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I certify that the above information is accurate and authorize All-Of-T to contact providers for coordinated care. I agree that the information that is provided can be used for HIPPA based documentation, evaluation and treatment purposes.

Parent/Guardian Signature and date below
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Date

MonthDayYear
Date
Upload a copy of insurance cards front and back, as well any additional supporting docs.
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INTAKE FORM

DEVELOPMENTAL HISTORY & MILESTONES

SENSORY PROCESSING & REGULATION