Child OT Intake
Please ensure you have 20-30 minutes to complete this form in its entirety, as your work cannot be saved and returned to at a later time. You must complete the entire form and submit it in one session.  

If you prefer, you may download the form directly from the website.

Thank you for your time to complete this form. It is lengthy, but is an important part of designing an individualized OT program for your child. This information provides the Occupational Therapist with complete and detailed information about your child and your concerns.  You will need to acknowledge the HIPAA Privacy Practices prior to starting this form.

Sign in to Google to save your progress. Learn more
Email *
Do you agree to the privacy policy? *
Child’s Name *
Birth Date:   *
MM
/
DD
/
YYYY
Address:   *
Home Phone:   *
Child’s Handedness:   *
Parents are: *
Child lives with (include relationship) *
Is child adopted or in foster care?   *
Parent/ Guardian (#1) Name *
Cell Phone *
E-mail Address of Guardian Completing this form: *
Occupation *
Parent/ Guardian (#2) Name if applicable
Cell Phone Parent/ Guardian (#2)
Email Parent/ Guardian (#2)
Occupation Parent/ Guardian (#2)
Names and Ages of Brothers and Sisters
Emergency Contact:   *
Emergency Contact Phone Number *
How did you hear about Boston Sensory Solutions? *
Referred By- please include address and phone number *
Pediatrician- please include address and phone number *
Medical Diagnosis:   *
Current Medications/ Supplements:   *
Current Precautions or Allergies *
Results of Hearing or Vision Tests:   *
Other Pertinent Medical Information:   *
School:   *
Grade:   *
Teacher:   *
Classroom Type:   *
Child has IEP ?     *
Date of IEP Annual Review:  
MM
/
DD
/
YYYY
Date of 3 - year Re-evaluation:  
MM
/
DD
/
YYYY
List Special Education Services and Service Providers:   *
Your perspective on current issues or concerns related to home   *
Your perspective on current issues or concerns related to school:   *
Your perspective on current issues or concerns related to peers/ extracurricular activities:   *
What particular skills would you like your child to gain in the next 6 months?   *
Is this your first evaluation for this concern?   *
If not, please list other evaluations and general results ( agency, date, outcome):  
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Boston Sensory Solutions, Inc.. Report Abuse
Google Forms