intake-packet Step 1 of 5 20% Child's Name* First Last Date of Birth* MM slash DD slash YYYY Sex* Male Female Diagnosis Child's Pediatrician School and Grade Mother's Name First Last Mother's Email Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmployer Occupation How do you prefer to be contacted?EmailCell PhoneHome PhoneWork PhoneFather's Name First Last Father's Email Father's Address If Different Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneWork PhoneCell PhoneEmployer Occupation How do you prefer to be contacted?EmailCell PhoneHome PhoneWork PhoneEmergency Contact Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Has your child ever experienced any of the following: Adenoidectomy ADD/ADHD Allergies Autism Ear Infections Ear Tubes Encephalitis Frequent Colds Head Injury Seizures Sensory Processing Disorder Sinusitis Sleeping Disorders Thumb/Finger sucking Tonsillectomy Vision Problems Do you feel your child has a hearing problem? Yes No If yes, please describeHas you child's hearing been tested or screened?* Yes No Date, Place and Results of TestIf child had/has ear infections how often: Has your child ever had ear tubes?* Yes No Date Received If child ever had a head injury, what was their age?Has you child had vision tested or screened?* Yes No Date, Place and Results of TestList Any Special Medical Needs/Devices/AFO's etc.List hospitalizations, operations accidents/injuriesList medications, dosages and reason for taking themWhat is your primary concern regarding your child at this time?List any allergies and/or diet/food restrictionsWhat are your child's personal interests and likes?What motivates them?What are your child's strengths?What are your child's dislikes?Please list any therapy services your child has received or is currently receiving through school, hospital, private practice or any other local agency.What do you hope to achieve from this visit?What are your long term goals for your child?Is there a language other than English spoken in the home? Yes No If Yes, Which one? Does the child speak the language? Yes No Does the child understand the language? Yes No Who speaks the language? Which language does the child prefer to speak at home? Speech-LanguageDo you feel your child has a speech problem? Yes No If yes, please describe.Has he/she ever had a speech/language evaluation/screening? Yes No If yes, where and when? What were the results?Has your child ever had speech therapy? Yes No If yes, where and when? What was he/she working on?Is your child aware of, or frustrated by, any speech/language difficulties?Has your child received any other evaluation or therapy (physical therapy, counseling, occupational therapy, vision, etc.)? Yes No If yes, please decribeWhat do you see as your child’s most difficult problem in the home?What do you see as your child’s most difficult problem in school?Does your child...(please select all that apply) repeat sounds, words or phrases over and over? understand what you are saying? retrieve/point to common objects upon request (ball, cup, shoe)? follow simple directions (“Shut the door” or “Get your shoes”)? respond correctly to yes/no questions? respond correctly to who/what/where/when/why questions? Your child currently communicates using body language respond correctly to who/what/where/when/why questions? Your child currently communicates using sounds (grunting, vowels) respond correctly to who/what/where/when/why questions? Your child currently communicates using words (shoes, doggy, up, etc.) respond correctly to who/what/where/when/why questions? Your child currently communicates using sentences longer than four words respond correctly to who/what/where/when/why questions? Your child currently communicates using anything else? Does your child have any Behavioral Characteristics: cooperative restless attentive poor eye contact willing to try new activities easily distracted/short attention plays alone for reasonable length of time destructive/aggressive separation difficulties withdrawn easily frustrated/impulsive inappropriate behavior stubborn self-abusive behavior Approximate age which your child achieved the following developmental milestonesBest guess of age is fine. If your child has not reached some of these developmental milestones because they are too young please disregard.Babbled: Said First Word: Put Two Words Together: Spoke in Short Sentence: Toilet Trained: Sat Alone: Crawled: Walked: Please share your main concerns about your child’s sensory/motor/self-care/feeding abilities:Please identify any strategies or interventions you have tried at home: Sensory MotorSensory Feeding/Oral Motor Check all that apply Does your child refuse new foods/texture? Does your child eat a very limited diet for age (10 or less foods?) Does your child drool excessively (past the teething stage)? Does your child refuse to have his/her teeth brushed? Does your child refuse to touch food with his/her hands? Does your child cry or tantrums inconsolably if spills food or drink on self? Does your child always have something in his/her mouth, or is chewing on clothes, hands, fingers (past the teething stage)? Does your child refuse to drink from any cup except for his/her 1 favorite cup? Sensory Feeding/Oral Motor Specifics: Gross Motor Seems weaker than other his age, tires easily Difficulty with hop, jump, skip, or run compared to others his age Clumsy, seems not to know how to move body, bumps into things, falls out of chair Tendency to confuse right and left Reluctant to participate in playground activities and sports; fearful of movement Slumps or slouches when seated, leans on others when standing Takes movement or climbing risks that compromise personal safety Is 'on the go' Becomes overly excitable during movement activity Likes to jump/hop/spin/throw self to the ground/bang into objects more than others Check all that applySensory Feeding/Oral Motor Specifics: Fine Motor Poor desk posture; slumps, leans on arm Difficulty managing fasteners (buttons/zippers/snaps/etc) needed for dressing Unable to tie shoes (if school age) Difficulty drawing, coloring, copying, cutting; avoidance of these activities Difficulty writing (if school age), head too close to work, other hand does not assist Poor pencil grasp; drops pencil frequently or holds on too tight Lines drawn are tight/ wobbly/ too faint or too dark/ breaks pencil often Lack of well established hand dominance after six years of age Unable to write his name legibly (if school age) Check all that applyTouch (tactile) Sensation Seems to withdraw from or react emotionally to touch, is bothered by tags/seams in socks Avoids getting 'messy' (ie. Finger paint, sand, glue, food stuffs) Shows distress during grooming (i.e. brushing of hair/teeth, nail clipping, hair cuts etc) Becomes irritated by shoes/socks or is sensitive to certain fabrics Dislikes being cuddled or hugged Walks on toes Picky Eater Tends to wear coat when not needed or won't take shoes off Seeks hugs Has trouble keeping hands to self, will poke or push others to the point of irritating them Unusual need for touching certain toys, surfaces, or textures Decreased awareness of pain or temperature; high tolerance Doesn't seem to notice when someone touches arm/back, or when hands/face are messy Check all that applyHearing Seems bothered by ordinary household sounds (vacuum cleaner, hair dryer, toilet etc) Holds hands over ears to protect ears from sound Responds negatively to unexpected or loud noises (i.e. cries or hides) Is distracted or has trouble completing tasks if there is a lot of noise or with background noise (i.e. radio, fan refrigerator, busy environment) Appears not to hear what is said (does not 'tune in') despite good hearing Child has difficulty making himself understood Appears to have difficulty understanding you Tends to repeat directions to self Check all that applyVision/Visual Perceptual Avoids or expresses discomfort with bright light; happy to be in the dark Covers eyes or squints to protect eyes from light Avoids eye contact; fleeting eye contact Looks carefully or intensely at objects/people/; enjoys watching objects that spin, light up Doesn't notice when people enter the room; doesn't notice changes in details Difficulty finding an object by color, shape, in a group; difficulty doing puzzles Difficulty paying attention if there is a lot to look at Bothered by busy visual environments (cluttered room or store) Difficulty copying designs, numbers or letters from paper (near point) or board (far point) Letter reversals after first grade Check all that applyEmotional/Behavioral Difficulty tolerating changes in routines, plans and expectations; does not accept changes Engages in rituals to complete personal routines Becomes easily frustrated Acts out behaviorally, difficulty getting along with others Seems oblivious in an active environment Displays excessive emotional outbursts when unsuccessful at a task Marked mood variations, outbursts or tantrums Uses inefficient ways of doing things (moves slowly, wastes time) Is impulsive, not waiting for full instructions or thinking before acting Jumps from one activity to another so it interferes with play Withdraws from social situations or hides from interactions Repetitive play, has difficulty coming up with ideas for new games/activities Check all that applyIs there any additional information you would like the therapist to know regarding your child:CAPTCHA
