Infant Intake Form

Infant Intake Form

Share your child’s details, feeding and development concerns, and emergency contact information.
Child & Parent Information
Child's Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Parent Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Best Phone Number for Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Payment Method
Insurance Type
Insurance ID
Group Number
Script for OT *if proceeding with insurance this is required

Cancelof
History
Reason for Evaluation
Feeding History
Describe the child’s current feeding habits and any difficulties
Has the child previously been evaluated or treated for feeding concerns?
If yes, who provided the previous evaluation or treatment?
Feeding position
Observed Feeding and Movement Concerns
Observed feeding difficulties
Muscle tightness or neck movement concern

1

2

3

4

5

1 is Full range of motion, 5 is Tight/unable to turn head
Asymmetry in head or neck movement
Sleep and Development
Usual sleep position
Developmental milestones achieved
Should be Empty:

History