Re-Assessment Parent Questionnaire
Your child is being re-evaluated by one of or all of their therapists. During a re-evaluation we update medical information, retest with standardized assessment tools and other objective measures, review goals and overall needs. We need your help to keep our information accurate and current. Please answer the questions below so we can keep your child’s information current and address all concerns you may have for your child.
Child's Name
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First Name
Middle Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
List any diagnoses given to your child:
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I. General Information
Describe what new concerns, if any, you have about your child:
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What areas do you feel have improved since the child's last assessment?
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What areas do you feel have NOT improved since the child's last assessment?
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II. Health History
Has any health history changed since the child's last evaluation (last 6-12 months)? Please include surgeries, vision or hearing changes, hospitalizations:
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Does your child have a specialized diet? Does your child have any food allergies? Does your child eat a variety of foods and are they able to take in adequate nutrition?
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What medication is your child currently on? Please include dosage and purpose of the medication.
III. Current Treatment
Does your child receive any other therapies besides at GASLC? If yes, where? Please provide therapists' names, etc.
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Please share any assistive equipment, tools, or supports your child uses to help them participate comfortably and confidently in daily routines (for example: communication devices, adaptive seating, mobility supports, feeding tools, orthotics, hearing aids, vision supports, sensory tools, etc.). :
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We welcome any observations about how your child interacts with their equipment, what works well for them, and anything you feel would help us ensure their tools continue to align with their strengths and support their overall well-being:
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What new goals/skills would you like your child to address in OT, PT, and/or Speech?
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IV. Behavior/Play
Please share any times where your child may need extra support with regulation or daily routines. You might include situations that are challenging, patterns you’ve noticed, or moments when your child appears overwhelmed, unsure how to express their needs, or has difficulty coping.
What do these behaviors look like?
What seems to help your child feel more regulated or successful?
What are your child’s interests, favorite play activities, toys, games etc.?
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What are your child's strengths?
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V. Current Educational Status
Name of school presently attending:
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Grade or level:
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Does your child have an IEP:
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Yes
No
Upload IEP here:
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of
Describe general progress and behavior in school:
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Is your child currently receiving any specialized educational supports or additional learning services (such as special education, small-group instruction, tutoring, or academic interventions)?
Yes
No
Other
If so, please share where these services take place (school, private provider, community program, etc.), what areas they support (communication, literacy, executive functioning, motor skills, social-emotional learning, academic skills, etc.)?
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VI. Additional Parent Comments
Please share anything that helps us better understand your child’s current needs, comfort, and overall well-being. Your insights ensure we provide care that aligns with your child’s strengths and supports their success across settings:
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Completed by:
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Relationship to Client:
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Email
*
example@example.com
Date
*
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Month
-
Day
Year
Submit
Should be Empty: