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Intake Form
Please complete this form if you are interested in participating in Individualized OT sessions at Wild Root Occupational Therapy. 
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Child's Name *
Child's Age *
Child's sex (assigned at birth) *
Guardian Name *
Relationship *
Parent Email address *
Address *
Phone Number *
What are you interested in?  *
OT Evaluation- It provides crucial information about your child's strengths and growth areas. It helps determine the most appropriate, and specific needs to be address in therapy sessions. If your child has an OT assessment within 12 month, I will use that assessment to inform goal setting for the treatment sessions. 
OT individual sessions are offered in a 10 session packaged- we will be meeting weekly and it includes individualized goal setting, progress reports at the end of the sessions and include two 30 minutes consult calls. 
Consultation Calls- 30 minutes phone calls to focus on addressing all your questions and concerns and offer resources to help your child's succeed in everyday life across multiple settings (create a home program). 
Do you already have an OT Evaluation that is less than 12 month old?  *
What is your Primary concern?  *
How did you hear about Wild RoOT?  *
What is the best way to reach you?  *
Any additional information you would like to share with me? 
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