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Returning Patient Update Questionnaire
Thank you for returning to GASLC! Because some time may have passed since your child was last seen, we ask families to complete this brief update form so our therapists can better understand your child’s current strengths, needs, routines, and supports. This form helps us provide care that is personalized, collaborative, and aligned with your child’s success across settings.
Child's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
List any diagnoses given to your child:
*
Discipline/s received in the past:
Speech Therapy
Occupational Therapy
Physical Therapy
Discipline/s looking to return to:
Speech Therapy
Occupational Therapy
Physical Therapy
I. General Information
What brings your child back to therapy at this time?
*
What concerns or challenges are most important for us to understand right now?
*
What goals or skills would you most like your child to work on?
*
What strengths, interests, or positive changes have you noticed since your child was last at GASLC?
*
II. Areas of Concern
Communication:
Understanding directions
Social communication
Using words/sentences
AAC needs / device use
Difficulty expressing wants/needs
Other
Motor Skills:
Balance / coordination
Social communication
Walking, running, jumping
Difficulty expressing wants/needs
Muscle weakness or stiffness
Difficulty with Stairs
Other
Fine Motor Skills:
Handwriting
Using buttons, zippers, or fasteners
Using utensils
Cutting with scissors
Other
Sensory Skills:
Tantrums or frustration tolerance
Difficulty transitioning
Difficulty participating in group activities
Difficulty following routines or expectations
Sensory seeking (constantly moving, difficulty sitting still, loves jumping/crashing, enjoys spinning, swinging and fast movement)
Sensory avoiding (avoids messy play, dislikes certain clothing textures or tags, avoids loud places, sensitive to bright lights, avoids touch)
Other
III. History
Has your child receive any therapies after services at GASLC? If yes, where and when? Please provide therapists' names, etc.
*
Please list any current medications, allergies, or important medical updates:
*
Has any health history changed since the child's last appointment at GASLC? Please include surgeries, vision or hearing changes, hospitalizations:
*
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.). :
*
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:
*
IV. Current Educational Status
Name of school presently attending:
*
Grade or level:
*
Does your child have an IEP:
*
Yes
No
Upload IEP here:
Browse Files
Cancel
of
Describe general progress and behavior in school:
*
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.)?
*
V. 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:
*
Completed by:
*
Relationship to Client:
*
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Submit
Should be Empty: