Child’s Name:Date of Birth:Today’s Date:Beyond Milestones Therapy: Occupational Therapy Intake FormPlease complete the following form to the best of your ability. We recognize that this can be a very overwhelming and time-consuming process, but the more information you provide, the better we can understand and help your child. Thank you in advance! Has your child received occupational therapy services in the past? ❏ YES. -- If Yes, please circle the settings that apply: School-based, Outpatient, or Both. ❏ NOWhat is the primary occupational therapy-based concern that you have for your child leading up to this evaluation? *What is the primary occupational therapy-based concern that you have for your child leading up to this evaluation? *What gain(s) has your child made over the past year that has made the most impact in his/her life? *What do you hope to see your child doing more independently or with greater ease one year from now? *What are your child’s strengths and interests?Strengths: *Interests: *The following check boxes will help us to guide the evaluation and treatment process. Please mark any of the boxes below that you feel describe your child. Marking the box indicates an area of difficulty or concern. Please describe any additional details/comments that you feel are relevant in each category below.Self-Careincreased assistance needed for dressingunable to follow simple hygiene routine (5 years and up)difficulty/delayed potty trainingpoor sleep habits (i.e.: trouble falling or staying asleep)difficulty with utensil use / self-feedingdifficulty managing/organizing school-materialsOther:Social Interactiondifficulty interacting socially and engaging with family and peers- loves to be around other children, repeatingdifficulty making friends- nodifficulty adapting to new environments- sometimesdelayed language skills- yes, diagnosed with mixed receptive language, ASD diagnosisoverly focused on one subject- yes, he can get fixateddifficulty coping in the school environment- yesOtherSensory Processing / Behavioroverly sensitive and responds negatively to loud soundsavoids touch from othersdifficulty/refusal with grooming (i.e.: hair brushing, bathing,)avoids/refuses to wear certain clothinglimited safety awareness; high pain toleranceconstantly moving, jumping, crashing, rockingenjoys hanging upside down (i.e.: over edge of couch)does not respond to name being calledshort attention spaneasily distractedimpulsivehyperactivelow energyemotionally reactive, frequent meltdowns or temper tantrumsdifficulty coping with change in routinesdifficulty, increased time required, increased behavior transitioning from preferred to non-preferred activities (i.e.: play to clean up, playground to home)inability to calm self when upsetdifficulty with multi-step tasks/directionsOtherMovement and Body Awarenessappears clumsy or uncoordinateddifficulty going up and down stairs at an age-appropriate timedifficulty with the concept of right and leftpoor ball skillstires easily; needs frequent rest breaks when playingtires easily; needs frequent rest breaks when playinghigh muscle tonepoor balancefearful of feet leaving the grounddoes not explore or enjoy playground equipmentdifficulty coordinating both sides of the bodydoes not cross midline of his or her body during play and school tasks (if known)does not cross midline of his or her body during play and school tasks (if known)OtherOral Motor/Oral Sensorydrools excessivelychews food in front of the mouth, rather than on the molarsdifficulty using a cup at an age-appropriate timedifficulty drinking from a straw at an age-appropriate timedifficulty weaning from bottle or breastfeedingappears to be excessively picky when eating, only eating certain types or textures of foodincreased mouthing of toys or objects beyond an age-appropriate timeOtherPlay Skillsdifficulty with imitative playneeds adult guidance to initiate playwanders aimlessly without purposeful playmoves quickly from one activity to the nextparticipates in repetitive play for hours (i.e.: lining up toys)does not join in with peers/siblings when playingdifficulty with concepts of sharing and turn takingOtherFine Motor Skillsdifficulty using feeding utensils at an age-appropriate timedifficulty manipulating toys and puzzlesseems to avoid tasks/games that require fine motor skillsdifficulty with pencil graspdifficulty with coloring, drawing, tracingpoor handwriting, letter/number formationnot developing a hand dominance at an age-appropriate time (by 5-6 years old)difficulty using scissorsdifficulty with clothing fasteners: zippers, buttons, shoelacesOtherVisual Processingdifficulty recognizing lettersmakes letter/number reversals after the age of 7difficulty copying shapes or lettersdifficulty with spacing and sizes of lettersloses place when reading or copying from the boarddifficulty finding objects among other objectspoor eye contactOtherHealth History: Please list any medical concern or history of significant pregnancy and delivery history as well as any diagnoses:Submit
