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New Concern/Additional Discipline Questionnaire
Your child is being evaluated by an additional discipline. This form allows you to share any new concerns, changes, or observations you have noticed in your child related to this discipline. Information from parents help us ensure that services remain aligned with your child’s needs. The information you provide supports coordinated care across disciplines and helps our team determine whether additional evaluation or therapy would be beneficial.
Child's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
List any diagnoses given to your child:
*
Please check all that apply:
I have new concerns about my child’s development.
I would like my child to be evaluated for an additional discipline.
My current therapist recommended seeking additional services.
Other
Discipline/s currently receiving:
Speech Therapy
Occupational Therapy
Physical Therapy
Discipline/s looking to add:
Speech Therapy
Occupational Therapy
Physical Therapy
I. General Information
What would you like to see improve with added services?
*
II. Areas of Concern
Communication:
Understanding directions
Social communication
Using words/sentences
AAC needs / device use
Difficulty expressing wants/needs
Other
Motor Skills:
Balance / coordination
Social communication
Walking, running, jumping
Difficulty expressing wants/needs
Muscle weakness or stiffness
Difficulty with Stairs
Other
Fine Motor Skills:
Handwriting
Using buttons, zippers, or fasteners
Using utensils
Cutting with scissors
Other
Sensory Skills:
Tantrums or frustration tolerance
Difficulty transitioning
Difficulty participating in group activities
Difficulty following routines or expectations
Sensory seeking (constantly moving, difficulty sitting still, loves jumping/crashing, enjoys spinning, swinging and fast movement)
Sensory avoiding (avoids messy play, dislikes certain clothing textures or tags, avoids loud places, sensitive to bright lights, avoids touch)
Other
III. History
Does your child receive any other therapies besides at GASLC? If yes, where? Please provide therapists' names, etc.
*
Please share any assistive equipment, tools, or supports your child uses to help them participate comfortably and confidently in daily routines (for example: communication devices, adaptive seating, mobility supports, feeding tools, orthotics, hearing aids, vision supports, sensory tools, etc.). :
*
We welcome any observations about how your child interacts with their equipment, what works well for them, and anything you feel would help us ensure their tools continue to align with their strengths and support their overall well-being:
*
IV. Current Educational Status
Name of school presently attending:
*
Grade or level:
*
Does your child have an IEP:
*
Yes
No
Upload IEP here:
Browse Files
Cancel
of
Describe general progress and behavior in school:
*
Is your child currently receiving any specialized educational supports or additional learning services (such as special education, small-group instruction, tutoring, or academic interventions)?
Yes
No
Other
If so, please share where these services take place (school, private provider, community program, etc.), what areas they support (communication, literacy, executive functioning, motor skills, social-emotional learning, academic skills, etc.)?
*
V. Additional Parent Comments
Please share anything that helps us better understand your child’s current needs, comfort, and overall well-being. Your insights ensure we provide care that aligns with your child’s strengths and supports their success across settings:
*
Completed by:
*
Relationship to Client:
*
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Submit
Should be Empty: