Groups Parent Assessment
Client Name *
Your answer
Client Date of Birth *
MM
/
DD
/
YYYY
Parent Name *
Your answer
Phone Number *
Your answer
Address *
Your answer
E-mail Address *
Your answer
Primary Diagnosis *
Your answer
Secondary Diagnosis
Your answer
Subjective History (age of diagnosis, medical history, past therapies & interventions, etc.) *
Your answer
Current Medication *
Your answer
Medical Precautions *
None
Present
Seizures
Diet
Allergies
Pain
Vision
Respiratory Concerns
Bowel Incontinence
Bladder Incontinence
Auditory
Oral Motor
Mobility
Notes on Above Information
Your answer
Behavioral Barriers to Participation
Your answer
Communication Skills
Your answer
Client/Caregiver's Concerns and Goals
Your answer
Current Recreation Functioning
Your answer
Physical Limitations or Impairments
Your answer
Highly Preferred toys, activities, reinforcements, etc.
Your answer
Sensory Precautions
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Reading Skills
Your answer
Writing Skills
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Color and Shape Recognition
Your answer
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