Therapy OPS Intake Form

Child Intake Form
Please Note: Every question included in this intake is used to adequately prepare for your child's evaluation (i.e., select appropriate assessments, prepare the evaluation space, etc). Each question must be answered before your evaluation can begin.
Today's date:*

MonthDayYear
Date
Child's First and Last Name:*
Child's Age:*
Child's Birth Date:*

MonthDayYear
My child is:*
Age of placement: *
"Other" explanation*
Sex*
Caregiver 1 Name:*
Caregiver 1 Cell Phone Number*

Area CodePhone Number
Please send me text reminders:*
I would like my reminder:*
Caregiver 1 Email address:*
Caregiver 1 Date of Birth:*
Caregiver 2 Name:
Caregiver 2 Cell Phone Number

Area CodePhone Number
Caregiver 2 Email Address:
Caregiver 2 Date of Birth:
If caregivers are not present in the session, therapists often check-in before and after the session to hear about any changes at home/school and what we did in therapy. We will ask you to join us in a room for any personal or in-depth updates. For routine check-ins, are you comfortable discussing this in the lobby? If not, we will ask you to join us in a private room. You may change your mind at any time, but please tell your therapist or the front desk.*
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Who currently lives with this child?*
How long have you lived here (St. Paul, south Metro, MN)?*
What brought you to this area?*
Physician/Primary Care Provider:*
Primary Care Provider Clinic Name:*
Primary language spoken in the home:*
How did you hear about us:*
Medical Diagnosis:
Allergies:
Current Medications:
School/Program of attendance:
Grade:
Does your child receive Special Education Services?*
If, yes, what?

AcademicBehavioralOccupationalSpeechPhysicalSocial SkillsD/APE
Describe your current concerns:*
Please list past evaluations and therapy:
Is your child currently receiving therapy at this time?*
If yes, what type of therapy and where?
Does your culture have a perspective on therapy? If so, tell us more:*
Family members that have any significant diagnoses (ADHD, learning disability, etc):
Prenatal/Birth History

Prenatal/Birth History*

	Yes	No	Unknown
Illness/Accidents during pregnancy
Pregnancy/delivery concerns
Full term
Alcohol/tobacco/medication use during pregnancy
Vaginal Delivery
C-section delivery
Assisted delivery (forcep, vacuum)
Feeding difficulties

Additional details for prenatal/birth history (weeks premature, concerns, etc):
Medical History
History of:*

SeizuresHistory of high feversPneumoniaSinusitisWhooping coughCroupTonsillitisChronic coldsEnlarged glandsHeart troublesAsthmaChronic ear infectionsTraumatic Brain InjuryOtherNone listed
Are immunizations current*
Explanation of medical history items:
Has your child ever had*

Serious/recurrent illnessesOperationsAccidentsVision problemsHearing difficultiesPE tubesDental problemsOtherNone listed
Description of above concerns:
Developmental Milestones
Did your child:
Sit up independently by 8 months?*
if no, at what age?
Sitting
Crawl by 11 months?*
if no, at what age?
Crawling
Walk by 15 months?*
if no, at what age?
Walking
Say first words by 16 months?*
if no, at what age?
First words
Combined 2 words by 24 months?*
if no, at what age?
Combine words
Dress self by 4 years?*
if no, at what age?
Dress self
Tie shoes by 6 years?*
if no, at what age?
Tie shoes
Drink from cup by 16 months?*
if no, at what age?
Drink from cup
Feed self by 3 years?*
if no, at what age?
Feed self
Functional Status
My child*
Percentage of independence completing:
Bathing*
Dressing*
Brushing Teeth*
Toileting*
Eating*
Riding a bike/tricycle*
Ascend/descend stairs*
Get up from floor without furniture or help*

Did you child have difficulty*

	Yes	No	Unknown
Sucking
Swallowing
Chewing
Changing to solids

When did pacifier use stop and how often was it used?*
Language Development
If your child has fewer than 15 words, please list them:
How long are your child's sentences*
Which sounds, if any, are incorrect?
How often do you understand him/her?*
How often do strangers understand?*
Does your child have difficulty following directions*
Does your child use language to tell you what they want and need without your help?*
Social Development

Would you describe your child as having:*

	Yes	No	N/A
Typical relationship with peers
Short attention Span
Impulsive
Tantrums/over-reacting
Nervous tics/behaviors
Difficulty learning new things
Poor safety awareness
difficulty taking others perspectives
aggressive behavior
difficulty attending events due to anxiety

How does your child handle separation/transitions?*
How does your child express anger?*
What, if any, are your behavioral concerns?
Current Status
Attention span for self-directed activities (not including TV, tablets, video games, etc)*
Attention span for adult-directed activities*
Favorite foods:*
Adverse foods (if any):
Favorite activities:*
Amount of time spent on screens on an average day (TV, phones, tablets, computers, etc)*
What typically motivates your child?*
What is your child's typical sleep pattern?*
How would you describe your parenting style?*
How do your values or beliefs shape your parenting decisions?
Tell us about the traditions/celebrations/rituals your family participates in.
Strengths, Areas of Improvement, & Goals
3 strengths of my child are:*
3 areas of improvement my child has are:*
3 goals I have for my child while in therapy are:*
Insurance Information and Signatures
Insurance Carrier:*
Policy Holder:*
Employer:*
Group Number:*
Policy Number:*
Does my child have secondary insurance?*
Secondary Insurance Policy Number:*
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Therapy OPS. I understand that I am financially responsible for any balance. I authorize Therapy OPS or my insurance company to release any information required to process my claims.

I have custody for the above minor and have been granted the right to legally make all health/therapy decisions regarding him/her. Please list others that share custody and are priveledged to health information:
Others than yourself who have custody of the above named minor:
Caregiver Signature*
Should be Empty:

Child Intake Form

Prenatal/Birth History

Medical History

Developmental Milestones

Functional Status

Language Development

Social Development

Current Status

Strengths, Areas of Improvement, & Goals

Insurance Information and Signatures