Occupational and Physical Therapy Report for Elks Camp Grassick

Occupational and Physical Therapy Report

for Elks Camp Grassick
To be completed if this individual is receiving or could benefit from occupational and/or physical therapy.
Name of Applicant

First NameLast Name
Birth Date

MonthDayYear
Diagnosis:
How does this individual ambulate?
If this individual uses a wheelchair, how independent is he/she in ADLs, transfers, mobility, etc.?
Does this individual wear orthotic devices?
What type of orthotic devices?
When do they wear their orthotics?
Occupational Therapist Information
Name of Individual's Occupational Therapist
Occupational Therapist's Email
example@example.com
School System or Agency of OT:
Address of School or Agency

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of School or Agency
Please enter a valid phone number.Format: (000) 000-0000.
If this individual is accepted, I would like to receive a copy of the report and follow up information after camp:
How would you like to receive information from camp?
Has this individual ever been evaluated for Occupational Therapy?
Is this individual presently receiving Occupational Therapy services?
How many times a week?
For what length of time?
What areas and/or concerns are being addressed in OT? Please give a brief description of therapy this individual is presently receiving.
Please indicate specific areas of concentration you would like addressed or certain skills you would like us to work on while this individual is attending camp.
Please include or attach any other information that you think would be helpful to our staff while working with this individual.
Please upload any pertinent files here.

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Physical Therapist Information
Name of Individual's Physical Therapist
Physical Therapist's Email
example@example.com
School System or Agency of PT:
Address of School or Agency

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of School or Agency
Please enter a valid phone number.Format: (000) 000-0000.
If this individual is accepted, I would like to receive a copy of the report and follow up information after camp:
How would you like to receive information from camp?
Has this individual ever been evaluated for Physical Therapy?
Is this individual presently receiving Physical Therapy services?
How many times a week?
For what length of time?
What areas and/or concerns are being addressed in PT? Please give a brief description of therapy this individual is presently receiving.
Please indicate specific areas of concentration you would like addressed or certain skills you would like us to work on while this individual is attending camp.
Please include or attach any other information that you think would be helpful to our staff while working with this individual.
Please upload any pertinent files here.

Cancelof
Should be Empty:

Occupational and Physical Therapy Report

Occupational Therapist Information

Physical Therapist Information