Therapy Intake Form

Child's Name

FirstLast

Gender

Date of Birth

Age

School

Grade Level

School/Daycare Schedule

Please List Preferred Days/Times for Therapy

Address

Street Address

CityState / Province

Postal / Zip Code

Email for Appointment Reminders

example@example.com

How did you hear about Sensory Kids?

Services you are interested in pursuing with Sensory Kids

Language(s) Spoken at Home

Health Care Provider Name (Pediatrician) and Phone Number

ALLERGIES

IF YES, PLEASE LIST

MEDICATIONS

IF YES, PLEASE LIST

DIAGNOSIS

IF YES, PLEASE LIST DIAGNOSIS

DATE OF DIAGNOSIS

DIAGNOSIS PROVIDED BY

Name of Physician/Provider

I have the legal right to give permission for therapy services, because my relationship to the child is:

Parent/Guardian Name - Primary

First NameLast Name

Parent/Guardian Preferred Pronouns

Phone Number - Primary

Please enter a valid phone number.Format: (000) 000-0000.

Email- Primary

example@example.com

Parent/Guardian Employer - Primary

Parent/Guardian Name - Secondary

First NameLast Name

Phone Number - Secondary

Please enter a valid phone number.Format: (000) 000-0000.

Email- Secondary

example@example.com

Parent/Guardian Employer - Secondary

Parent/Guardian Preferred Pronouns

Voice/Text Message Approval

Who will be involved in the child's therapy?

(List names and relationships of everyone in the home)

Is there anything I need to know about contacting the people listed above?

Custody arrangements, divorce stipulations, etc

Emergency Contact (When neither guardian can be reached)

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Relationship to Child

Please list other professionals your child has worked with in the past (therapist tutors, counselors etc.) Name, Phone, Currently working with?

Describe your reason for seeking Occupational Therapy/Speech Therapy services, how long has this reason influenced you/your life?

What have you tried to do to resolve these matters on your own? In what way(s) was this helpful?

Labor and Delivery Information

Childs Birth Weight

Gestational Age

By Week

Please describe any pregnancy or birth complications

Feeding

Feeding comments (i.e. picky eater, swallowing difficulties etc.)

Did child meet all developmental milestones? (i.e. crawling, walking, etc.)

Does your child have any medical conditions?

If yes, describe condition (G-tube, seizures, diabetes, juvenile arthritis, etc)

List hospitalizations, surgeries, and injuries (broken bone, tonsillectomy, concussion, etc) with dates

Recent testing (MRI, swallow study, x-rays, hearing test, ADHD, IQ, genetic testing, etc.)

Are you transferring services or adding additional services from another provider?

If Transferring or adding please tell us where from.

What are your thoughts about how Sensory Kids may be able to help?

Please share anything you think is important for us to know that we may have missed:

Please list your Child’s Strengths

Does your child have an IEP?

Any skills they have acquired and then lost? How is your child with turn taking/direction following? How do they interact with other children?

Does your child become frustrated if they are unable to communicate their wants/needs? What does that look like?

Are you concerned about your child's speech sound production? If so, please explain.

Did your child use 1 word by the age of 1 year?

Did you child begin using 2 words by the age of 2 years old?

Does your child currently speak using 3+ word sentences?

Approximately how many words does your child currently have?

Does your child currently use sign or gestures to communicate?

If yes, what signs/gestures?

Does your child currently use a communication device to speak?

If yes, what device?

Does your child try to get you to notice interesting objects?

When you point to a toy across the room, does your child look at it?

Does your child engage in pretend play with toys (i.e. feed a doll?)

Does your child play well with other children?

Do you have any concerns regarding socialization? If yes, please explain.

How does your child communicate in different settings? Home, community, school, etc.?

Did child pass newborn hearing screening?

Has your child had a history of ear infections or tubes placed.

Has your child had hearing testing done since the newborn screening? If so please list results. (Date of testing)

Is there a history of speech/language delays on either paternal or maternal side. (i.e. Speech or Language, Stuttering, Hearing loss, Cleft Palate, Autism Spectrum, Developmental Delay, Reading or Learning Disability, ADHD). If yes, please explain.

Parent/Guardian Signature

Sensory Kids New Client

Please fill out the following if you are interested in speech therapy: