Intake Form

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Welcome!

By completing this Intake Form, we would be able to identify which assessment is appropriate for your child. Please complete all required fields.

Name of Child

Date of Birth

Age

Diagnosis (if applicable)

Gender

Female Male Prefer Not to Say

Address

Name of Parent/Guardian

Email of Parent/Guardian

Telephone

Is your child currently receiving other interventions or therapies?

Yes No

If yes: select current intervention or therapies?

None Speech and language therapy Audiology Occupational therapy Physical therapy Applied Behavior Analysis (ABA) Psychology Other

Does your child attend nursery or school?

Yes No

Were there any complications during pregnancy?

Yes No If yes, explain

If yes, explain below.

Did mother take medications during pregnancy?

Yes No If yes, explain

If yes, explain below.

Type of Delivery

Vaginal Cesarean

Were there any complications during birth?

no premature birth breathing difficulty incubation jaundice transfusion forceps feeding difficulty congenital defects emergency cesarean other complications

Was your child in the NICU?

No Yes

Does your child have any allergies?

No Yes

Has your child had any of the following? Check all that apply:

seizures/epilepsy Broken limps Gastro-intestinal problems Asthma allergies surgeries birth defect/genetic disorders anemia/ blood disorder failure to thrive feeding problems kidney/renal disorder neurological disorder visual concerns digestive problems head injuries none of the above

Has your child had a hearing test?

No Yes

Has your child had an eye exam?

No Yes

What are your concerns? Please check all that apply.

fine motor skills gross motor skills handwriting self-care skills inattention to task/ poor executive functions skills visual perceptual skills developmental delay poor sensory processing skills

Do you have any other concerns? Kindly list concerns below.

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