Intake: History & Background

Initial Intake Form

PATIENT HISTORY AND BACKGROUND
Child's Name

First NameParent
Date of birth

MonthDayYear
Date
My child is going to be evaluated for:

Breastfeeding and Lactation supportOccupational Therapy AND/OR Physical TherapySpeech & Language Services
Parent/Caregiver Name

First NameLast Name
Parent Email
example@example.com
Occupation of parent/caregiver
Other Guardians/Alternative Care Providers

First NameLast Name
Occupation of additional parent/caregiver
How did you hear about Kids In Motion
Primary Doctor

BIRTH & MEDICAL HISTORY
List all medical conditions or diagnoses your child has been told they have or that you are suspecting?

Gestational Information

	Yes	Notes
C-Section
Breech
Failure to thrive
Underwieght
NICU Stay
Premature
Gestational Diabetes
Pre-Eclampsia
Maternal High Blood Pressure

Were there any difficulties during pregnancy or delivery?
Has your child had any of the following?

Difficulties with keeping head in one position (torticollis)Flat headHistory of foot deformities including club foot or metatarsus abductusHistory of hip displasiaXrays or ultrasound of the hip or neckSkin conditions, birth marksLip Tongue Tie/ReleaseDifficulty with latching for breastfeeding or bottle feeding
If yes, please explain?
Treatments tried (therapy, chiro, essential oils, diet restrictions, etc.)
What is your child currently doing well emotionally and developmentally? What are their strengths?
What are your PRIMARY concerns and primary problems regarding your child's development.
Medications and/or allergies?
Is your child currently in good health? Past surgeries or imaging and injuries?
Living Environment: Please describe your home?
Who lives in your home?
Is there any similar diagnoses or problems in your family? Please describe:
Are there any precautions the therapist should be aware of when working with your child?
Safety Concerns:

Can't report getting hurtFrequently trips and fallsNo awareness of dangerInappropriate sexual behaviorsToo impulsivePhysical aggression towards othersDoes not learn from experienceUnsafe around traffic / crossing the streetBolts/ runs offHas no "stranger danger" awarenessNot safe around sharp or hot itemsDoes not respect other's personal boundariesEasily influence by peers, could do something unsafe they say to do without thinking about the consequencesAccidentally hurts self or others due to poor coordinationExcessive number of accidents (bumps and bruises self often)Sudden outburstsPoor choices affecting safetyChokes on food or liquidsDoes not learn from experienceNot safe around sharp or hot itemsDoes not respect other's personal boundariesNone
Describe your child as an infant:

EasyAverageAlertActivePassiveQuietEnjoyed cuddlingSociableDifficultColickyCried a lotFussyResisted being heldFloppy when heldTense when heldGood sleep patternsIrregular sleep patternsExcessive restlessnessHead bangingI don't know (e.g. foster/adopted)
Does your child prefer one hand over the other?

Yes, Right handedYes, Left HandedNoI don't know
Describe how your child moves around their home or environment.

My child usually plays on the floor or is heldUses an assistive device such as crutches, walker, gait trainerUses a power wheelchairUses a manual wheelchairWalks and moves independentlyWalks and moves independently but falls a lotMy child has a prosthetic limb
Assistive Devices

Shoe inserts or AFO/SMOCaneWalkerWheelchairHoyer LiftGait TrainerStanderAdaptive VehicleAdaptive toilet seatOther special seating equipmentAdaptive technology

Breastfeeding and Lactation
Midwife/OBGYN Name
Midwife/OBGYN Email
Midwife/OBGYN Phone Number
What was your due date?

MonthDayYear
PRGENANCY
Any irregularities or concerns with your menstrual cycle?

YESNO
Any challenges with your fertility?

YESNO
Are you currently using birth control? If yes, please list.
Oral contraceptives, IUD, or other
What changes have you noticed in your breast during your pregnancy? (select all that apply)

Grew largerLeaking colostrumSensitive nipplesTendernessDarker areolasPainOther
Any issues you had during your pregnancy? (Select all that apply)

Nonehigh blood pressurecerclagepremature contractionsanemiagroup B strephyperemesisbed restgestational diabetesinfectionOther
Where did you deliver your baby?
Select any interventions you had during your labor. (select all that apply)

nonecytotecepiduraluse of forcepsinternal monitoringc-sectionepisiotomyPitocinvaginal flushmembranes strippedfoley balloonIV fluidsuse of vaccuumantibioticswater brokenOther
Challenges during the birth (select all that apply)

nonefevertearinghemorrhageplacental abruptionOther
How long was your total labor?
How long was your pushing stage?
Did your baby have any challenges? (check all that apply)

noneshoulder dystociainternal monitoringcord around neckmeconium aspirationlow apgar scoreNICU stayIVforcepsbreech presentationcord prolapsesuctioningfeveraundiceantibioticsvacuumtransverse presentationheart deceleration/fetal distressdifficulty breathinginfectionlow blood sugarNG or Peg TubeOther
How many days did you remain in the hospital? (N/A for home birth or birth center)
Postpartum complications (check all that apply)

nonelow BPmood disorderfeverhigh BPinfectionUTIOther
FEEDING HISTORY:
Did your baby latch within the first 2 hours of birth?

YESNO
If no, please explain:
Did you receive lactation support after your birth?

YESNO
If yes, please explain:
Are you experiencing any of the following? (check all that apply)

latching difficultiescracked/bleeding nipplescrease, flat, blanched nipples after nursingincomplete breast drainagebaby slides off nipple when trying to latchsore nipplesbaby has a preference for one breastengorgementbaby not interested in breastbaby fall asleep shortly after started feedingthrushmastitisbaby always seems hungrycolicbaby excessively gassylots of spit up (soaking bibs)Other
Are you using any of the following? (check all that apply)

NoneMedela SNSCupNipple ShieldLactAidSpoonBottleSyringeOther
What are you feeding your baby?

Exclusively BreastmilkExclusively FormulaMajority BreastmilK, some FormulaMajority Formula, some BreastmilkEqual amount Breastmilk and Formula
If Formula feeding, which type/brand?
What brand of bottle are you using?
Do you currently notice any of the following during bottle feeding? (check all that apply)

refusal of bottlecoughing or sputteringgaggingmilk leaking from mouthchewing or chompingextended time to finish bottlefinishing bottle in less than 5 minutesnone
What is the flow rate of the nipple?
Did someone instruct you to thicken or fortify your baby's bottles?

YESNO
If yes, who instructed you to do this and what are you using to thicken of fortify?
If you are currently using a breast pump; which pump are you using, how many ounces total are you pumping each time, how many times per day and how many minutes each time? If you are using a breast pump, N/A.

Have you introduced any of the following foods? (check all that apply)

Nonecereals (rice, oats, etc.)pureewhole foodsfruitslegumes (beans, etc.)meatdairyfishOther
How often are you offering solid foods?
How much solid food are you offering? (1 tbls, 1/4 cup, etc.)
Please list all weights that you have for your baby from birth to now:
BABY HISTORY

How did your baby's most recent poop look? (check all that apply)

yellow and seedytarry/blackbrownmucusgreenbloodyOther
Has your baby received a diagnosis of tongue tie, lip tie, or buccal/cheek tie? If yes, please describe
If your baby has a surgical release of their tongue tie, lip tie, or buccal/cheek ties please answer the following:
Doctor's Name
Date of Procedure

MonthDayYear
Date
Details:
Specialists currently working with my child:

Occupational Therapy- community/medicalOccupational Therapy- early interventionSpeech Therapy- community/medicalSpeech Therapy- early interventionPhysical Therapy- community/medicalPhysical Therapy- early interventionSpecialist PhysicianNeurologistOrthopedistChiropractorDietician/NutritionistDentist or Orofacial MyologyMassage TherapistOther
PARENT HISTORY
Do you presently have, or have you had, any of the following? (check all that apply)

Noneanemiathyroid disorderdiabetesdepressionanxietyhigh blood pressureconstipationyeast infectionPCOSinfertilitycancerinsulin resistancemuscle aches and painsretained placentarefluxtongue tievisual impairmentinsomniasleep disorderautoimmune disorderfatigueOther
List any medications you are currently taking, or have plans to resume while breastfeeding
List any supplements or herbs you are currently taking, or have plans to resume while breastfeeding
Please list any food or environmental allergies:
What is your current pain level?

1

2

3

4

5

6

7

8

9

10

1 is no pain curently, 10 is Most pain I can imagine
Please describe the source of the pain you are currently experiencing
Any prior breast surgeries or piercings? (check all that apply)

Nonebiopsyimplants (behind muscle)implants (in front of muscle)reductionpiercings
Family history (check all that apply)

Nonefood allergiesrefluxtongue tieOther
If you intend to return to work/school, please describe your schedule and your baby's schedule.
How would you rate your level of stress?

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Select any diet restrictions (check all that apply)

Gluten freeDairy freeVeganVery healthyFairly healthypoor

SPEECH LANGUAGE
How much do you understand your child?

Never0-25% of the time26-50% of the time51-75% of the timeGreater than 75% of the timeAll the time
How much do less familiar people (grandparents, aunts, uncles, etc.) understand your child (0%-100%)?

Never0-25% of the time26-50% of the time51-75% of the timeGreater than 75% of the timeAll the time
Early Speech & Language Skills (Birth to 2 years Old)

BabblingPointing or using gestures to communicate.Trying to imitate wordsStopping/pausing when hearing “no” or their nameFollows simple directions with gesturesFollows simple directions without gestures.Uses sounds /p, b, m, n, d, w, h/ when babbling or using wordsWaves or says “hi” or byeListens to short stories, songs, or rhymes

Speech & Language (3 and above years)

	Yes	No	Sometimes
Following directions similar to peers
Uses sentences to communicate wants and needs
Answers yes/no questions
Answers “wh-“ questions
Asks Questions
Engages in conversation
Can state personal information when asked
Retell a story
Uses grammatically correct sentences
Respond to Greetings
Make Requests
Describe Events
Take Turns
Follow Commands
Make Eye Contact
Repeat
Attend to Tasks
Maintain Topic
Role-Play
Sequence Actions
Define Words
Categorize
Understand Object Functions
Initiate Activity or Dialogue

Fluency

Gets stuck on wordsCan’t get their thoughts across in a single sentenceRepeat wordsHolds a sound out longer than normal
Voice

Raspy voicehorse soundingPitch appears higher than peers

FEEDING
Do you have concerns with eating, mealtimes, drinking, and variety of foods? If you answer no, please move on to next section.*

YesNo

Swallowing & Feeding

	No	Sometimes	Often	Always
Fatigue easily during meals
Choke/coughing when eating or drinking
Are messy eaters
Difficulty drinking from a straw or open cup
Difficulties with swallowing during/after drinking or eating
Difficulty with liquids
Difficulty with foods
Difficulty swallowing medicines
Reports feeling "lump" in throat
Complaints of pain when swallowing
Wet or gurgly voice after swallowing
Pocketing food in cheeks
Unexplained weight loss
Indigestion or burning reported
Coughing or choking while eating/drinking
Acidy or metallic taste in mouth upon waking
Longer time to finish meals
Throat clearing after swallowing
Dry Mouth
Runny nose after eating

Feeding History

	Yes	No	Sometimes	Notes
Feeding tube
Breast-fed
Bottle-fed
Finger feeds
Cup with spout
Straw drinking
Spoon
Fork
Open cup drinking
Knife
Stage 1 baby food
Stage 2 baby food
Stage 3 baby food
Table foods
Sweet
Sour
Bitter
Bland
Salty
Spicy
Smooth purees (smmothie, applesauce)
Chunky purees (peas/carrots cooked)
Soft solids (ground hamburger, noodles)
Hard solids (steak, carrots, granola bar)
Hot foods
Warm foods
Room temperature foods
Cold Foods

How many meals does he eat a day with snacks?
Where does your family eat your meals?
Response to feeding

Arches backChokingCoughingCryingDifficulty chewingDroolingEats too fastEats too slowFails to chew foodFrequently changes nippleGaggingGetting down from tableHiccuppingHolding food in mouthNasal regurgitationPockets foodPoor intakeRefluxRefuses to open mouthRefusing to eatSpillage of food/liquidSpits out foodStuffs mouthThrowing food/objectsTurning head awayVomitingWet vocal quality after eating

OCCUPATIONAL HISTORY
In one sentence how would you describe your child?
In one sentence how would you describe yourself?

CHILD PROFILE (FINDINGS)
My child often loses their balance:

No problemsWhen not moving, they just seem unstable and will fall overWhen challenged with an activity or new environmentUses hands or things around our home to balance when moving
Behaviors in day to day routines:

Avoidant Behaviors with difficult tasksDecreased working memory affecting ability to learnDefiant behaviorsImmature or inappropriate behavior for ageDifficulty transitioning between activitiesCries or fusses with interactionDecreased attention spanEasily distracted by environment, sounds, noiseEasily frustrated with challenging tasksDoes not make eye contact appropriatelyDifficult to quiet at appropriate timesQuiet but interactiveHas difficulty sitting stillLacks confidence in their abilitiesInappropriate use of toysArm Flapping or motor ticsChild requires encouragement for engagement in activitiesUnusual fearsDifficulty learning new tasksThrows temper tantrums
Cognition

No concerns or not age appropriateMy child has difficulty with telling time, identifying familiar places, people, or situationsI feel like my child has difficulty with short term memoryI feel like my child has difficulty with long term memoryMy child has difficulty with figure out the order of tasksMy child has difficulty with problem solving simple tasksMy child is unable to follow 1 step directionsMy child is unable to follow multiple step directionsMy child has difficulty with attentionMy child has difficulty initiating activitiesMy child has difficulty with stopping an activity
Comments regarding cognition:
General Communication Skills

Able to communicate using gestures and pointingDifficulty expressing feelings and emotionsCommunicates primarily through pointing and gesturesParent/Caregiver communicates child's needsNon-VerbalAttempts to verbally communicate but is difficult to understandDifficulty understanding simple phrasesIgnores verbal interactionUses sign languageHearing impairedUses communication boardLearns best through demonstrationLearns best with verbal directionLearns best with hand-over-hand demonstrationLooks for source of voiceMakes appropriate eye contact when speaking with childVocalizes sounds but is not intelligibleDifficult to quiet at appropriate timesIs able to remain quiet at appropriate times
Endurance & Fatigue

My child is in good physical healthI am worried about my child's physical health due to sedentary activity or obesityMy child fatigues faster than other children in their peer groupsMy child naps often after physical activityMy child appears to be out of shape or have difficulty with play due to poor endurance

Motor Planning

My child has low muscle toneMy child has high muscle toneMy child has difficulty forming ideas and concepts for everyday activities or playIt is difficult for my child to initiate and control their muscle function and voluntary movements.My child has difficulty with timing their muscles to complete tasks. Movements can be slow, off target, too fast

Posture

No concernsMy child has poor posture when standing, sitting, squatting, bendingMy child has difficulty with uneven surfaces, running, biking, or higher level postural demands

	Notes
Where does your child complain of pain?
Is there anything that makes pain worse? Activities, events, clumsiness
Anything that helps it?
How does your child describe their pain

SENSORY PROCESSING SYSTEMS
Auditory

Responds negatively to unexpected or loud noisesHolds hands over ears to protect from soundsDistracted / trouble functioning with noiseCan't work with background noiseDoesn't respond to being called by nameEnjoys strange noises / makes noisesDifficulty maintaining auditory attentionDifficulty shifting from one task to anotherDistractible to irrelevant stimuliSlow adaptation to relevant auditory stimuliDifficulty understanding non-verbal cuesDifficulty understading nuances of languageDifficulty following a simple request with a verbal/motor responseDifficulty with filtering of auditory inputDislikes noisy items such as vacuum, lawn mower, etcDifficulty selecting a primary message from background noiseEasily distracted by environmental soundsOversensitive to sounds / frequently covers earsAble to retain auditory information in orderDifficulty retaining auditory information in orderUnder-aroused by incoming stimuli
Visual

Discomfort / avoids bright lightsHappy to be in the darkDifficulty finding objects in busy backgroundBothered by bright lightsCovers eyes or squints in lightsLooks intensely at objects / peopleEasily distracted by environmentAvoids eye contactPrefers to be in the darkAble to recognize shapes and formsAble to visually localize requested object from environment
Tactile

Avoids getting messy (paste, sand, paints, etc)Distressed during groomingPrefers long sleeve when hot / short when coldDiscomfort with dental / brushingSensitive to certain fabricsIrritated with socks / shoesAvoids going barefootReacts emotionally or aggressively to touchWithdraws from splashing waterDifficulty standing close to othersRubs / Scratches spots that have been touchedUnusual need to touch objects / people / surfacesDecreased awareness of pain / temperatureDecreased awareness of touchAvoids wearing shoes / prefers barefootDoesn't notice messy hands / faceDistressed by changes in clothing
Oral

Gags easily with textures / utensils in mouthAvoids certain tastes, foods, smellsWill only eat certain foods, tastesLimits self to food textures, temperaturesPicky eaterFrequently smells non-food objectsStrong preference for certain smellsStrong preference for certain tastesCraves certain foodsSeeks out certain tastes, smellsChews or licks non-food objectsMouths objects (hands, pencils, etc)
Vestibular

Becomes anxious/distressed w/feet off groundDislikes activites with head upside downAvoids moving equipment/toysDislikes riding in a carSeeks movement activitiesTwirls/spins (likes dizzy feeling)Rocks unconsciouslyRocks in desk/chair/floorLoves to spin, swing and jumpReluctance to engage in new postures and positionsSlumped, rounded postureUncomfortable with open spaces such as a shopping mallUncomfortable with playground activitiesUncomfortable with stepsUncomfortable with surface changes on the floor
Proprioceptive

Low muscle toneHigh muscle toneAvoids climbing or jumpingChild does not move around or explore his environmentJumps excessivelyPoor gross and fine motor controlSeeks deep touch pressureSeeks movement that interferes with daily life
Multi-Sensory Processing

Gets lost even in familiar placesDifficulty paying attentionLooks away from tasks to notice action in roomOblivious within an active environmentHangs on people / furniture / objectsWalks on toesLeaves clothes twisted on body

Visual Motor Skills

Avoids eye contactDoes not spontaneously track or look for target objectDoes not visually explore or examine an objectHesitates going up and down stepsPrefers to be in the darkIllegible handwritingTalks to self while writingWatches hand while writing
Bowel and Bladder Function

No ConcernsWets bedHolds Urine or Stool due to fear or painFrequent Urinary Tract InfectionsNight wettingConstipationStreaking in underwearNot Toilet trained
If you marked any Bowel & Bladder concerns, please describe below.

FUNCTIONAL ACTIVITIES (Exploring environments, play, leisure, school and daycare)

Developmental History

	Currently Unable To	Delayed	Met on Time	I don't know
Rolled by 7 mo
Crawled by 10 mo
Reached by 6 mo
Finger fed by 16 mo
Ate with spoon by 2 yr
Drank from open cup by 18 mo
Dressed self by 3 yr
Clothing fasteners by 4yr (tie bow by age 6)
Toilet Trained by 4 yr
Draw a circle by 3 yr
Cut with scissors by 4 yr
Use knife for cutting by 5 yr
Walked by age 13-16 mo
Jumped by 3 yr

What are your child's favorite activities or what do they love doing the most?
What does your child avoid or dislike the most?
Social Play Skills

Play alonePlay next to other childrenShares with other childrenPlay with other childrenEngages in conversation
Comments:

Please describe the problems with self care

EDUCATIONAL/THERAPY HISTORY
Is your child school age?

YesNo
Does your child attend daycare or preschool?

YesNo
If yes, how many days a week and how many hours each day?
Current classroom placement:

Regular classesMy child is on an IEPGifted classesHomeschool
Does your child comprehend directions as well as other children?

YesNoI Don't Know
Comments:
Has your child had to repeat a grade?
What grade is your child functioning in?
For example, above for math, below for reading, grade level for writing
Academically is your child:

Needs some help to accomplish class workAverageAdvanced
Socially and behaviorally is your child:

Functioning well, gets along with others, no behaviorsAverage, needs some assistance some timesStruggles with making or keeping friendships, negative behaviors towards others or self or has difficulty with social groupsOther
Do your child's teachers describe any of these problems?

TransitionsHandwritingAttentionCopying from BoardReadingHomeworkSitting at DeskFine MotorSocial SkillsRecess PerformanceSportsSit During MealFrequently gets up and walks aroundWon’t wait for turnDoes not respect the rights of othersDoes not cooperate well in groupsShouts outDoes not wait to be called onTypically does better 1:1Does not pay attention during circle time or lectureDifficulty with Individual work timesDifficulty with small groupsDifficulty with free playDifficulty with field trips/special assemblies /movies / class discussion
Specialists currently working with my child:

Outside agency such as HIT, ENABLE, Community OptionsMy child receives respiteOccupational Therapy -Community / MedicalOccupational Therapy- SchoolSpeech Therapy Community / MedicalSpeech Therapy - SchoolPhysical Therapy -Community / MedicalPhysical Therapy - SchoolPsychologist / Counselor - Community / MedicalPsychologist / Counselor - SchoolBehaviorist - Community / MedicalBehaviorist - SchoolDevelopmental OptometristSpecialist PhysicianNeurologistOrthopedistReading Specialist / Tutor - CommunityReading Specialist - SchoolWriting Specialist / Tutor - CommunityWriting Specialist / Tutor - SchoolMath Specialist / Tutor - CommunityMath Specialist / Tutor - School
Comments:
Please describe a typical day for your child from waking until bedtime (describe difficulties in routines such as going to sleep, staying asleep, etc) Please any information that will help us know your child better.
Activity Level

Given my child's diagnosis, the activity level is appropriateMostly quietLethargic slow movementsTires easilyOverly activeTalks constantlyRestlessMore active than siblings or other children same ageActs like driven by a motor
Comments:
How are your family's everyday activities affected by these concerns and problems? Are there things that you cannot do but would like to as a result of these concerns?
In one year, it would be amazing if my child could.......What goals do you have for your child related to therapy services? Please list 2 to 4 priorities that you would like to achieve.
What do you feel is limiting your child from doing this now?
Approximately when did you start noticing your concerns and is it getting better, worse, or staying the same in the past 6 months?

What social supports does your family have or need?
Overall what is your level of concern?

1/10 Mild2/10 Mild3/10 Moderate4/10 Moderate5/10 Moderate6/10 Moderate7/10 Severe8/10 Severe9/10 Severe10/10 Severe
Overall how often do you experience these difficulties with your child?

Multiple times a dayOnce a day2x per week3x per week4x per week5x per week6x per weekOther
As the primary caregiver to this child, I prefer to have information for home programming:

Discuss during services and provide me paper handoutsDiscuss during services and email me on an app I can use to track exercises with instructions and videosI am a visual learnerI learn best by listening
Parent/ Legal Guardian's Signature

Clear
Date Signed:

MonthDayYear
Date
Should be Empty:

	0	1-3	4-7	8-12	13+
# of Breastfeeding sessions
# of Bottle feeding sessions
# of other feeding sessions (cup, syringe, tube, etc.)
# of Solid feeding sessions
# of Pumping sessions
# of ounces expressed from left breast (if pumping)
# of ounces expressed from right breast (if pumping)

	0	1	2-3	4-5	6+
Wet diapers
Poopy diapers

	Likes	Dislikes or Avoids
Protein
Dairy
Vegetables
Fruits
Grains
Other

	Yes	No	Needs Help	Any thoughts?
Does your child feed himself?
Does he use fingers?
Does he use fork?
Does he use spoon?

	Unable	Poor quality/coordination	Notes
Due to my child's diagnosis these are all difficult
Coloring
Cutting
Handwriting
Holding an object in each hand for at least 5 seconds
Locating objects in theraputty
Picking up small objects with tweezers
Picking up small objects

	Unable	Poor quality/coordination	Notes
Due to my child's diagnosis these are all difficult
Going up and down stairs
Swing and pump legs
Heel to toe walking
Running speed and agility
Wheelbarrel crawling
Catch and throw a ball
Riding bicycle
Animal walks
Jumping
Climbing
Obstacle course/Climbing
Hops on one leg
Kick a ball
Bounce a ball
Crab crawling
Somersault

	Poor Strength	Poor movement/Mobility	Any thoughts?
Ankle
Elbow / Forearm
Hand - Strength
Hip
Knee
Shoulder
Spine
Wrist

	Does not get into this position	Needs Help	Independent
Prone on Elbows
Rolling
Prone to Sit
Sitting
Moving from Sit to Crawl
Crawling
Hands & Knees
Sit to Kneel
Tall Kneeling
Standing
Kneel to Stand
Walking

	Needs Physical Help	Needs step by step verbal help	Needs Reminders	Can do it independently
Feeding self
Eating
Dressing
Grooming
Bathing
Sleeping
Personal Hygiene
Toileting
Transitions between activities

	Not a problem	Helps our family or is a resource we use	We lack resources in this area or feel this is a barrier	NOTE
Physical Layout of my home
Physical layout of places we go in the community
Sensory factors in the environment (allergies, lights, sounds, air quality)
Physical demands on parent or child
Cognitive demands on parent or child
Social demands on parent or child
Attitudes of teachers, staff, other supports
Child's peer relationships
Safety at school
Access to transportation
Programs and services availability
Supplies availability such as technology, toys, etc
Time that family members spend with child
Family and friends
Financial means and resources

Initial Intake Form