Form
Parent's Name
First Name
Last Name
Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Grade/School Attending (2026-2027 School Year)
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.)
Feeding/Picky Eating
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 (please check all that apply)
Tuesday AM (9-12pm)
Tuesday PM (1-4pm)
Wednesday AM (9-12pm)
Wednesday PM (1-4pm)
Thursday AM (9-12pm)
Thursday PM (1-4pm)
Friday AM (9-12pm)
Friday PM (1-4pm)
Saturday AM (830-1230pm)
Saturday PM (1-4pm)
Afterschool Preference (4-7pm)
Other
Name of Referring Person/Professional
Is there anything else you would like me to know about your child?
Submit
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