Future Client Questionnaire

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Your Name *

Phone Number *

Email *

Child's Name *

Primary Care Physician

We require a referral, please reach out to your Primary Care Physician.

Insurance *

What are your areas of concern? (Check all that apply)
*

Motor Movement (fine-motor/ finger or hand use and manipulation of objects and gross-motor/walking, running, jumping)

Activities of Daily Living (bathing, dressing, eating, feeding, personal hygiene, toileting)

Balance and Coordination (stand on one leg, ride a bike, catch a ball)

Social Participation (making friends, having conversations, reading emotions or gestures of others)

Rest and Sleep (sleep preparation, participation, quality)

Cognitive development (trouble remembering things, paying attention, making decisions, problem solving)

Education and Learning (school, family, community participation)

Sensory Processing (degree in which a child (1. receives, 2. is bothered, 3. interprets, 4. misses) sensation)

Attention (active engagement in activity, shared or paying attention towards others)

Self-regulation (cognitively aware-proper body positioning-emotionally stable)

Speech (sounds of speech, fluency of speech, can you understand the speech)

Language (can the child express themselves, do they understand directions)

Feeding (pocketing foods, overstuffing, coughing, choking, etc.)

Difficulty with breast-feeding and/or bottle-feeding

Other:

Required

If your child shows any of the following signs, they may benefit from a feeding evaluation:

difficulty swallowing (e.g., coughing, choking, red or watery eyes, wet or gurgly-sounding voice during or after meals), poor weight gain or slow growth, ongoing mealtime challenges (such as refusing to try new foods or extreme picky eating), a very limited diet (fewer than 20 different foods), difficulty transitioning to solid foods, or strong reactions to certain food textures, tastes, or smells.

What is your most significant area of concern?
*

Preferred Appt Day/Time *

Any other information you'd like us to know? *

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