Parent/Caregiver Information for Occupational Therapy Screening
Parent's Name
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Parent's Address
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phone number
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email address
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Your Child's Full Name
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Date of Birth
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YYYY
Age
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Grade
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School
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Please describe the reason you are seeking an OT screening.
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What information would you like to gain from this OT screening?
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Tell me about your child's areas of interests/strengths.
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Where is your child most comfortable and successful? (example-home, school, sport activity)
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Describe any challenges your child or you are currently facing?
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Are these recent challenges...describe when the challenges started.
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Have these patterns of behavior changed over time?
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Please describe the impact these behaviors have on your child's success at home, school, and in other situations.
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Please describe any recent life/family experiences that may be impacting your child. Has there been any recent change in the family structure (birth of a new child, sickness, divorce, death of relative, etc).
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Describe any other barriers that are affecting your child's success.
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Tell me about your child's birth and medical history including developmental milestones.
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Is your child independent with dressing and other self help skills? Please describe any issues or concerns.
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Is your child a picky eater? Please describe.
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Does your child seem sensitive to sensation (clothing, movement, sounds, food items, etc)?
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Does your child seek out sensation (excessive movement, touching objects, etc)?
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Does your child have difficulty paying attention? Does your child seem impulsive?
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Describe your child's ability to calm and self-regulate. What strategies does your child use for self-regulation?
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Describe your child's school related skills (handwriting, fine motor), and independent participation. Please identify any concerns you may have.
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Please describe your child's motor skills, coordination skills, endurance and strength. Does your child complain of fatigue, or do you notice endurance issues?
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Would you describe your child as generally coordinated?
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What sport or physical activities does your child enjoy/participate in?
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Are there any barriers to your child's success in the motor area?
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Please describe any services your child is currently or will be receiving?
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Please add any additional information you would like me to know about your child.
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I sincerely appreciate the opportunity to work with you and your child. Thank you for completing this form today.
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