Therapy OPS Intake Form

Child Intake Form
Please Note: Every question included in this intake is used to adequately prepare for your child's evaluation (i.e., select appropriate assessments, prepare the evaluation space, etc). Each question must be answered before your evaluation can begin.
Today's date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's First and Last Name:
Child's Age:
Child's Birth Date:

MonthDayYear
My child is:
Age of placement:
"Other" explanation
Sex
Parent/Guardian 1 Name:
Relationship to child
Parent/Guardian 1 Cell Phone Number

Area CodePhone Number
Please send me text reminders:
I would like my reminder:
Parent/Guardian 1 Email address:
Parent/Guardian 1 Date of Birth:
Parent/Guardian 2 Name:
Relationship to Child
Parent/Guardian 2 Cell Phone Number

Area CodePhone Number
Parent/Guardian 2 Email Address:
Parent/Guardian 2 Date of Birth:
Who has legal custody of the child?

Other
Who is legally authorized to make health care/therapy decisions for the child?

Other
Is there a court order, custody agreement, guardianship document, Delegation of Parental Authority (DOPA), or other legal document that affects who may make health care decisions or receive information about this child?
Please upload any applicable documents:

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Is anyone other than a parent or legal guardian authorized to make health care/therapy decisions for this child?
If yes, please provide their name
Relationship to the child
Type of Legal Authority (please provide a copy of the current documentation via email or fax)

Other
Are there any restrictions on contacting or providing information to any parent, guardian, or other individual associated with this child?
Please explain
Please provide documentation (if different from above upload)

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If caregivers are not present in the session, therapists often check-in before and after the session to hear about any changes at home/school and what we did in therapy. We will ask you to join us in a room for any personal or in-depth updates. For routine check-ins, are you comfortable discussing this in the lobby? If not, we will ask you to join us in a private room. You may change your mind at any time, but please tell your therapist or the front desk.
Child's Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Physician/Primary Care Provider:
Primary Care Provider Clinic Name:
Who currently lives with this child (parents, siblings, grandparents, roommate, etc)?
How long have you lived here (St. Paul, south Metro, MN)?
What brought you to this area?
Primary language spoken in the home:
How did you hear about us:
Medical Diagnosis:
Family members that have any significant diagnoses (ADHD, learning disability, etc):
Describe your current concerns:
Please upload any recent evaluations or reports that may be helpful (e.g., IEP, recent neuropsych reports, etc)

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Prenatal/Birth History

Prenatal/Birth History

Rows	Yes	No	Unknown
Illness/Accidents during pregnancy
Pregnancy/delivery concerns
Full term
Alcohol/tobacco/medication use during pregnancy
Vaginal Delivery
C-section delivery
Assisted delivery (forcep, vacuum)
Feeding difficulties

Additional details for prenatal/birth history (weeks premature, concerns, etc):
Developmental Milestones
Did your child:
Sit up independently by 8 months?
if no, at what age?
Sitting
Crawl by 11 months?
if no, at what age?
Crawling
Walk by 15 months?
if no, at what age?
Walking
Say first words by 16 months?
if no, at what age?
First words
Combined 2 words by 24 months?
if no, at what age?
Combine words
Dress self by 4 years?
if no, at what age?
Dress self
Tie shoes by 6 years?
if no, at what age?
Tie shoes
Drink from cup by 16 months?
if no, at what age?
Drink from cup
Feed self by 3 years?
if no, at what age?
Feed self
Medical History
History of:
Explanation of medical history items:
Has your child ever had
Description of above concerns:
Allergies:
Current Medications:
Are immunizations current
Current Education Setting and Therapy
School/Program of attendance (including daycare/preschool):
Grade:
Does your child receive Special Education Services?
If, yes, what?
Please list past evaluations and therapy:
Is your child currently receiving therapy at this time?
If yes, what type of therapy and where?
Does your culture have a perspective on therapy? If so, tell us more:
Functional Status
My child
Percentage of independence completing:
Bathing
Dressing
Brushing Teeth
Toileting
Eating
Riding a bike/tricycle
Ascend/descend stairs
Get up from floor without furniture or help

Did your child have difficulty

Rows	Yes	No	Unknown
Sucking
Swallowing
Chewing
Changing to solids

When did pacifier use stop and how often was it used?
Language Development
If your child has fewer than 15 words, please list them:
How long are your child's sentences
Which sounds, if any, are incorrect?
How often do you understand him/her?
How often do strangers understand?
Does your child have difficulty following directions
Does your child use language to tell you what they want and need without your help?
Social Development

Would you describe your child as having:

Rows	Yes	No	N/A
Typical relationship with peers
Short attention Span
Impulsive
Tantrums/over-reacting
Nervous tics/behaviors
Difficulty learning new things
Poor safety awareness
difficulty taking others perspectives
aggressive behavior
difficulty attending events due to anxiety

How does your child handle separation/transitions?
How does your child express anger?
What, if any, are your behavioral concerns?
Current Status
Attention span for self-directed activities (not including TV, tablets, video games, etc)
Attention span for adult-directed activities
Favorite foods:
Adverse foods (if any):
Favorite activities:
Amount of time spent on screens on an average day (TV, phones, tablets, computers, etc)
What typically motivates your child?
What is your child's typical sleep pattern?
How would you describe your parenting style?
How do your values or beliefs shape your parenting decisions?
Tell us about the traditions/celebrations/rituals your family participates in.
Strengths, Areas of Improvement, & Goals
3 strengths of my child are:
3 areas of improvement my child has are:
3 goals I have for my child while in therapy are:
Insurance Information and Signatures
Insurance Carrier:
Policy Holder:
Employer:
Group Number:
Policy Number:
Does my child have secondary insurance?
Secondary Insurance Policy Number:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Therapy OPS. I understand that I am financially responsible for any balance. I authorize Therapy OPS or my insurance company to release any information required to process my claims.

I have custody for the above minor and have been granted the right to legally make all health/therapy decisions regarding him/her.
Parent/Guardian Signature*
Should be Empty:

Child Intake Form

Prenatal/Birth History

Developmental Milestones

Medical History

Current Education Setting and Therapy

Functional Status

Language Development

Social Development

Current Status

Strengths, Areas of Improvement, & Goals

Insurance Information and Signatures