Pediatric Sensory Intake Form
Please complete this form to help us better understand your child’s sensory profile and daily experiences.
Child’s First and Last Name
*
First Name
Last Name
Child’s Age
*
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Preferred Contact Method
*
Email
Phone
Text Message
Which sensory experiences does your child typically seek out?
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Movement (jumping, spinning, swinging)
Touch (soft fabrics, messy play, fidgeting)
Sounds (music, humming, making noises)
Visual (lights, colors, patterns)
Oral (chewing, mouthing objects, tasting)
Other
Which sensory experiences does your child tend to avoid or dislike?
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Loud noises
Bright lights
Certain textures (clothing, food, materials)
Strong smells
Crowded or busy environments
Other
What are common triggers for sensory overload in your child?
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What strategies or supports help your child feel calm and comfortable?
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Describe any daily routines or activities that are important for your child’s sensory needs.
*
Additional comments or information you’d like to share about your child’s sensory profile.
Submit
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