Occupational Therapy Intake Form

Pediatric Occupational Therapy Intake Form

Share your preexisting conditions, daily activity needs, and current equipment details.
Pediatric Patient's Full Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent or Legal Guardian's Name

First NameLast Name
Relationship to Child
Best Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best Contact Email Address
example@example.com
Patient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child's School
Current Grade
If not currently enrolled, put in what their grade should be.
Teacher
Preferred Service
What Kind of Occupational Therapy is Requested?
Diagnosis & Medical History

Select All that Apply
Choose any that apply

Other
Other Diagnosis or Medical Information to Share
Birth Complications & History
Elaborate Birth Complications or Relevant Birth History if Necessary
Developmental History & Current Services
Age When Started Walking
Age for First Words
Toilet Trained?
Current Services Receiving
Areas of Concern

List any areas the child may be struggling with or have sensitives to
Sensory
Fine Motor and School
Self-Care and Participation
Current Symptoms and Concerns
Any Falls in the Last 12 Months?
If Yes, How Many
Family History

Please include any relevant family history notes below
Relevant Family History

Other
Who was affected?
Other Diagnoses We Should Be Aware of
Other Symptoms
If Applicable
Home Environment
Home Type
Home Access
Living Arrangements
Current Equipment and Devices

Equipment Regularly Used or Patient has In Possession
Mobility
Seating & Positioning
Bathroom & Daily Living
Splinting & Technology
Other device, Available Brand/Model Information or Equipment Concerns
Any Current Medications We Should Be Aware of?
Parent/Guardian Goals for Occupational Therapy

What are you hoping your child will get out of OT?
What would you most like to accomplish through occupational therapy?
What would success look like after therapy?
Anything else you would like us to know?
Please Upload Any Relevant Medical Files

Cancelof
Legal Acknowledgement
Next Steps

Complete the form and select Submit Intake. Neuro Rehab LLC will contact you to discuss scheduling and the most appropriate service.
Should be Empty:

Pediatric Occupational Therapy Intake Form

Diagnosis & Medical History

Developmental History & Current Services

Areas of Concern

Family History

Home Environment

Current Equipment and Devices

Parent/Guardian Goals for Occupational Therapy

Next Steps