Form
Parent's Name
First Name
Last Name
Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Grade/School Attending
OT Areas of Need
Fine Motor Skills (i.e. grasping a writing tool, drawing, coloring, cutting etc.)
Printing/Handwriting Skills
Sensory Processing
Self-Regulation/Emotional Regulation
Retained Primtiive Reflexes
Executive Functioning Skills (i.e. attention/focus, planning, organizing, memory etc.)
Do you have OT benefits/health insurance?
Please Select
Yes
No
Do you currently have an FSCD contract?
Please Select
Yes
No
I have applied and am awaiting a contract
Availability and Preference for OT Sessions (based on OT availability)
Tuesday PM (1:00-5:15pm)
Wednesday PM (1:00-5:15pm)
Thursday PM (1:00-5:15pm)
Friday AM (9:00-12:00pm)
Friday PM (1:00-4:00pm)
Name of Referring Person/Professional
Submit
Should be Empty: