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Occupational Therapy Intake Form (page 2)

Sensory and Motor Development

My child is more sensitive to sensory experiences more so than most people in the following areas:

Audio (hearing)

Visual

Movement

Taste

Smell

Tactile (touch)

Check all areas of challenge (might have been covered in the questions above)

Gross Motor

Fine Motor

Oral Motor

Visual Motor

My child has trouble learning new movements

Yes

No

Maybe

My child tends to be clumsy and has balance or coordination problems

Yes

No

Maybe

Social-Emotional and Behavior Abilities

Check the areas of strength

Cheerful

Mature

Sense of Humor

Two-way interactions

Cooperative

Attentive

Self-Controlled

Separates well

Has Social Interactions

Positive Self-Esteem

Positive Self-Regulation

Cooperates

Check the areas of challenge

Two-way interactions

Cooperative

Attention

Self-Control

Separation from parent(s)

Social Interactions

Self-Esteem

Positive Self-Regulation

Cooperation

Anxiety

Depression

Aggression

Controlling

Fearful

Adaptive and Self-Care

Check the areas of Challenge

Feeding

Dressing

Toileting

Grooming

Goals

What are your goals for your child's program? What are the lagging skills? Be specific - what time of day, what environment?

1.

3.

2.

4.

What is your availability?

How did you hear about Oak Bloom OT? Referred by?

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©2021 by Oak Bloom OT