Occupational Therapy Intake Form

1

Child's Name

First Name

Last Name

2

Date of Birth

Date

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.

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

39

Phone Number of Parent/Guardian

Please enter a valid phone number.