Date of Birth:
What grade is your child in?
What school does your child attend?
Phone Number (home and/or cell):
Does your child currently receive services at DTA?
If yes, please list the name of the therapist that your child is currently seeing.
If no, does your child currently receive services elsewhere?
If yes, where and how often?
Include the name, location, duration and frequency of the visits.
Please attach any evaluations and assessments from other providers, including the place and date.
Please list any other services that your child currently receives (i.e. school services).
How did you hear about us?
Word of mouth
What handwriting curriculum does your child's school use?
Are you familiar with the Handwriting Without Tears program?
Which of the following has your child been taught?
Do you have any concerns with your child's pencil grasp?
What are your fine motor or visual motor concerns about your child? (e.g. scissor skills, coloring in the lines, pencil grasp, etc.)
Please describe to the best of your ability, the level of skill your child has in regards to handwriting. Please be as descriptive as possible in addressing your concerns.
Please attach a current sample of your child's handwriting or a drawing.
For us to get to know you and your child better.
Please describe any diagnoses, medical conditions, current medications, allergies, dietary restrictions, adaptive devices or precautions to be considered.
What are you hoping your child gains from this clinic?
What are your child's strengths? What are his/her interests?
Strategies that help your child or strategies that have been tried so far:
Please describe other "specialized" services or experiences that your child has had (e.g. handwriting tutoring, etc.).
Please list any additional information that would help us understand your child better.
***Please bring in current samples of your child's handwriting/drawings to the screening.
Should be Empty: