Occupational Therapy Intake Form

You can always press Enter⏎ to continue

Now create your own Jotform - It's free!Create your own Jotform

Occupational Therapy Intake Form

Occupational Therapy Intake Form

Hi there, please fill out and submit this confidential form to help us get to know your child.

38Questions

Language

English (US)

1
Child's Name
First Name
Last Name
2
Date of Birth
Date
Year
Month
Day
3
Please indicate areas of concern:
Dressing
Feeding
Toileting
Motor Skills/Coordination
Social Interactions
Playing
Sleeping
Homework/School work
4
Please indicate the area of concern that has the biggest impact on your family life.
5
Please indicate your child's level of independence with dressing.
Child can independently dress self
Child needs occasional assistance to dress
Parent dresses child on a daily basis
6
Can your child zip and button clothing?
YESNO
7
Child can push arms through sleeves and legs through pants?
YESNO
8
Please rate the level of importance for your child to be independent with dressing at this time.
Not at all important. This rarely adds stress to our daily life.
Very important. This has a high impact on our daily life.
9
Do you have concerns about your child's eating habits?
YESNO
10
Child is a picky eater or will only eat certain foods?
YESNO
11
Child eats an adequate amount of food for his/her age?
YESNO
12
Please select level of independence with utensils.
Child uses spoon/forks at every meal
Occassionally needs reminders to use utensils
Never uses utensils
13
Child is willing to sit at a table/high chair for meals?
YESNO
14
Please rate the level of importance for your child to be independent with feeding at this time.
Not Important: This does not add stress to our daily life
Very Important: This is a source of stress in our daily life.
15
Please indicate your child's independence with toileting
Not toilet trained
Occasionally uses the toilet with assistance
Uses the toilet most of the time
Completely independent with toileting
16
Please indicate your child's level of independence with hand washing
Does not tolerate/participate in hand washing
Completely dependent. Does not wash hands independently.
Washes hands with assistance
Washes hands independently
17
Child appears clumsy or uncoordinated?
YESNO
18
Child has difficulties with handwriting?
YESNO
19
Child fatigues easily or has poor endurance?
YESNO
20
Child has difficulties learning new motor skills?
YESNO
21
Motor skills make it difficult for my child to participate in age appropriate activities.
YESNO
22
Does your child play with age appropriate toys?
YESNO
23
Pretending with ObjectsPlease select the highest level you consistently observe.
Does not use objects to pretend
Uses real objects
Substitutes objects for other objects
Uses imaginary objects
24
Role-PlayingPlease select the highest level you consistently observe
No role playing observed
Uses one sequence/action of play
Combines sequences/steps/tasks in play
Uses verbal declaration (for example, "I'm a doctor.")
Imitates actions of role, including dress
25
Verbal Communication during a play episodePlease select the highest level you consistently observe
Does not verbally communicate during play
Talks during play only to self
Talks only to adults in play
Talks with peers in play by stepping outside of their role (for example, "That's how mommies do it.")
Talks with peers from within the role (for example, "Eat your dinner kids.")
26
Persistance in PlayHow long does your child typically engage in an episode of play?
Less than five minutes
Six to nine minutes
Ten minutes or longer
27
Play with Others
Plays alone
Plays only with adults
Plays with on child, always the same person
Plays with one child, can be different partners
Can play with two or three children together
28
Community interactions are limited due to my child's current level of play.
YESNO
29
Does your child respond when his/her name is called?
YESNO
30
Does your child have difficulties with transitions to new activities/environments?
YESNO
31
Does your child have difficulties with changes in routines?
YESNO
32
Does your child have a low frustration tolerance?
YESNO
33
Does your child demonstrate safety awareness within the home/community?
YESNO
34
Does your child have difficulty calming and/or coping with anger when upset?
YESNO
35
Do you have concerns about your child's ability to play with other children?
YESNO
36
My child's temperament/social interactions impacts our ability to participate in activities within the community?
YESNO
37
Does your child have a significant fear, aversion, or difficulty with any of the following items?Select all that apply
Washing/cutting hair
Cutting finger nails
Brushing teeth/oral care
Loud and unexpected noises
Clothing textures/fabric
Avoids swings/climbing
Avoids messy play/getting dirty
38
Do any of the following statements describe your child?Select all that apply
My child has difficulty calming down
My child has difficulty focusing their attention
My child engages in risky or dangerous play activities
My child prefers rough play
My child is constantly moving
My child appears to crave movement
Should be Empty:

Question Label

1 of 38See AllGo Back

Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Save your progress

OR

Already have an account? LOGIN

Skip Create an Account

Save your progress

Name

Email Address

Password

I agree to theTerms of ServiceandPrivacy Policy

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Save your progress

OR

Username or email

Password

Forgot Password?

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.