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