Inquiry Form
Please complete the following questions so I may better understand your child's strengths and challenges to determine the right interventions to match your child's needs. Please note that the information you share below will be kept private and confidential per the United States HIPPA privacy standards. Information shared is accessible only by your occupational therapist, Dr. Elizabeth Joy Shaffer.
Your Name
First Name
Last Name
Your Child's Name
First Name
Last Name
Parent's or Caregiver's Email
example@example.com
Phone Number
Please enter a valid phone number.
Child's Gender
Female
Male
Transgender
Gender neutral
Non-binary
Prefer not to say
Other
Age
City & Country
How motivated do you feel your teen is in personal development or overcoming current challenges?
Not at all (but may be open to the idea)
1
2
3
4
Motivated about getting support & guidance.
5
1 is Not at all (but may be open to the idea), 5 is Motivated about getting support & guidance.
Life rating: How well do you think your child is doing at school?
Barely getting by
1
2
3
4
Excelling
5
1 is Barely getting by, 5 is Excelling
Life rating: How well do you think your child is doing socially?
Barely getting by
1
2
3
4
Excelling
5
1 is Barely getting by, 5 is Excelling
What major problem or issue DO YOU FEEL your child is facing at this moment?
What major problem or issue does YOUR CHILD FEEL they are facing at this moment?
How much is this problem impacting their life now?
Not at all
1
2
3
4
Very well
5
1 is Not at all, 5 is Very well
What is in the way of solving the current problem or issue?
What have you tried in the past to help your child with this current problem or challenge?
Please list any diagnosis, developmental delays, learning difficulties your child has or is experiencing.
Please list your child's strengths and interests.
What is your goal for interventions?
Do you have any additional questions, concerns, or thoughts you want to share?
Thank you
Within three days, you will receive an email to set up a time to discuss the next steps and have any additional questions you may have answered. If you have yet to receive an email from me within 3-days of completing this form, please check your spam folder or contact me by email at elizabeth@therapyintl.com. I look forward to working with you and your child.
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