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:
Check all areas of challenge (might have been covered in the questions above)
My child has trouble learning new movements
My child tends to be clumsy and has balance or coordination problems

Social-Emotional and Behavior Abilities

Check the areas of strength
Check the areas of challenge

Adaptive and Self-Care

Check the areas of Challenge


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


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