Occupational Therapy Intake Form

To gain more information about how to best serve your child or young adult and family. HIPPA compliant and confidential personal history.

Personality Profile

What are the areas of challenge for your child?
Has your child been diagnosed with (PLEASE CHECK ALL THAT APPLY):

Medications

Family Adaption

The dynamics between child and family members

How would you describe your child's general adjustment at home?

Pregnancy & Birth

Developmental Milestones

Did your child meet developmental milestones on time (i.e., walking by 15 months, talking by 1 year)
Please check childhood illnesses/problems (Check all that apply)

Previous Testing and Treatments

Please check the assessments that you have had

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

Goals

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

phone  415-216-7089

email  oakbloomOT@gmail.com

   Â©2020 by Oak Bloom OT

phone  415-216-7089

email  oakbloomOT@gmail.com

   Â©2020 by Oak Bloom OT