Occupational Therapy Intake Form
Child’s Name: Date:
Age: DOB: Gender:
Address: Phone (home):
City: Zip: (cell):
Insurance Provider: Member ID:
Who referred you?
Primary Care Physician Phone:
Address: Fax:
School or daycare:
Name and phone number
Ethnicity: Caucasian African American Native American, Tribe Alaskan Native Hispanic Asian or Pacific Islander Other:
How would you describe your concerns about your child?
How long has this been a problem?
How serious is the problem right now? 1 2 3 4 5 6 7 8 9 10
How hopeful are you that things can get better? 1 2 3 4 5 6 7 8 9 10
How have you tried to solve the problem(s) before now?
Reason(s) you are seeking services: (check all that apply)
Aggression Depression Adjustment problems
Anger Anxiety Family stressors
Tantrums Grief/Loss Chaotic environment
Excessive crying Bonding/Attachment Parent-child problems
Physical abuse Irritability Worry
Emotional abuse Impulsiveness Pulls hair
Sexual abuse Sleep problems Feeding problems
Neglect Hyperactive Runs away
Aches/illness complaints Nightmares Poor social skills Problems with siblings Head banging Imaginary friend(s)
Cruel to animal Multiple losses Underweight
Bad language Problems in school Problems in child care
Divorce Custody Acts out in public
Smears feces Bedwetting Wets self in daytime
Hoarding food Seems sad Fearful/fear of dying
Hurts self Difficult to console/soothe Sexual acting out Problems with authority Oppositional/defiant Mood swings
Withdrawn Overly sensitive Low energy/fatigue
Trauma Separation anxiety Biting
Setting fires Cruel to animals Developmental delay
DEVELOPMENTAL HISTORY
Child’s primary caregiver(s) during the first three years: Complications during pregnancy: Y N
If YES, describe
Was child born full term: Y N If NO, at how many weeks: How old was the child when he/she:
Sat alone: Crawled:
Walked: Slept through the night:
First words: Said Mama/Dada:
Combined words:
MEDICAL
Date of last medical appointment: Results:
Current medications (including prescription and over the counter medications):
Are child’s immunizations current: Y N
Date child’s vision screened: Date child’s hearing screened: Child is allergic to the following food(s)/medication(s):
Other allergies: Child’s current weight:
Any concerns about the child’s weight/eating habits: Y N If YES, describe:
Any ongoing health needs of the child? If so, please describe and include the date of onset and how it impacts the child’s functioning:
Is the child currently receiving treatment for this?
Please list current therapies that you child is participating in: Occupational Therapy Services Provider:
Physical Therapy Services Provider: Speech Therapy Services Provider: Other therapy Services Provider:
Has the child experienced any of the following: (check all that apply)
Fainting/dizzy spells Constipation/diarrhea Lupus
Unable to move a body part Headaches Meningitis
Swelling Stomach aches Pneumonia
Kidney/bladder problems Ulcers Diabetes
Liver disease Abnormal thirst Heart problems
Measles Strep throat Cancer
Frequent colds/sore throats Lice Anemia
Concussion(s) Head injury Thyroid disease
Asthma Mumps Blood clots
Dislocation(s) Glaucoma Hepatitis
High blood pressure Seizures/epilepsy Reflux
Tonsils/Adenoids removed Stitches Broken bone(s)
Tubes in ears Ear infections How many
ADOPTION
Does this child have an adoption history? Y N If NO, please skip this section. How long was your child placed with you prior to the adoption?
How many placements did your child have before they were placed with you? When was your family’s adoption finalized?
CUSTODY
Who has legal custody of the child?
Do either parent’s rights supersede the other’s?
Child’s parents: Married Divorced Never Married No Contact
Deceased Who: How:
Child’s age at time of death or separation:
If parents are divorced or not living in the same home, describe with whom the child lives and the visitation schedule with the other parent:
If the child is or has been in DHS custody or you are the not the child’s biological parent, please explain the circumstances:
DHS Caseworker: Phone:
Judge: County:
CASA: GAL:
Attorney: Next Court Date:
SIGNATURES
