Your Name:* Phone*Child's Name:* Birthday* MM slash DD slash YYYY What is the biggest concern you have regarding your child?*Does your child current or has he/she previously received any therapy services? If current, please list name and email address:*Medical History:Significant birth history?*Siblings? Please include names and ages (list any previous therapies received):*Significant surgical history?*Significant recurrent health problems (including asthma, ear infections, etc.)?*Current medications?*Primary language?* Community activities (including sports teams, classes, park district programs, play groups, church groups, etc)?*Self-Help SkillsIs your child able to complete the following:FeedingFeed with fork* Independent Needs assistance Not yet completing Feed with spoon* Independent Needs assistance Not yet completing Drink from an open cup* Independent Needs assistance Not yet completing Drink from a straw* Independent Needs assistance Not yet completing Please explain feeding here if necessary:DressingPut on shirt* Independent Needs assistance Not yet completing Put on pants* Independent Needs assistance Not yet completing Put on shoes/socks* Independent Needs assistance Not yet completing Remove shirt* Independent Needs assistance Not yet completing Remove pants* Independent Needs assistance Not yet completing Remove shoes/socks* Independent Needs assistance Not yet completing Able to do buttons* Independent Needs assistance Not yet completing Able to do zipper* Independent Needs assistance Not yet completing Please explain dressing here if necessary:GroomingBrushing teeth* Independent Needs assistance Not yet completing Brushing hair* Independent Needs assistance Not yet completing Bathing* Independent Needs assistance Not yet completing Toilet training* Independent Needs assistance Not yet completing Please explain grooming here if necessary:Sleeping Please explain current sleeping habits, including location, amount, and quality:*Fine Motor CoordinationDo you have any concerns regarding your child’s use of his/her hands? If so, please explain?*Do you have any concerns regarding schoolwork, including cutting, handwriting, etc.? If so, please explain?*Misc.Is your child able to follow basic directions? Please explain if necessary.*What is your child’s preferred method of communication? Please explain if necessary.*Do you have any concerns regarding your child’s attention? If so, please explain?*Do you have any concerns regarding your child’s transitions between tasks? If so, please explain?*Do you have any concerns regarding your child’s behavior? If so, please explain?*What are preferred toys or activities for your child?*What are your goals for your child? What would you like to see your child accomplish?*
