Therapy Questionnaire

Child's First Name *

Child's Last Name *

Child's Date of Birth * +

Caregiver's First Name *

Caregiver's Last Name *

Email Address *

Street Address *

Address Line 2

City *

State *

Zip Code *

Cell Phone Number * 🛈

Mother's Place of Employment *

Mother's Work Phone Number * 🛈

Father's Place of Employment *

Father's Work Number * 🛈

Primary Health Insurance Company *

Primary Health Insurance Policy Number *

Who referred your child for occupational therapy, physical therapy, or speech therapy services? *

Doctor

Self-referred

Friend

Other Other

Please state the name of the person who referred the service.

Please select complications, if any, that describe your child’s birth history. *

Please give the approximate ages when your child accomplished major developmental milestones. *

	0-3 Months	4-6 Months	7-8 Months	9-10 Months	11-12 Months	13-18 Months	19-24 Months	25+ Months
Reaching	0-3 Months	4-6 Months	7-8 Months	9-10 Months	11-12 Months	13-18 Months	19-24 Months	25+ Months
Sitting Independently	0-3 Months	4-6 Months	7-8 Months	9-10 Months	11-12 Months	13-18 Months	19-24 Months	25+ Months
Crawling	0-3 Months	4-6 Months	7-8 Months	9-10 Months	11-12 Months	13-18 Months	19-24 Months	25+ Months
Walking Independently	0-3 Months	4-6 Months	7-8 Months	9-10 Months	11-12 Months	13-18 Months	19-24 Months	25+ Months
Babbling	0-3 Months	4-6 Months	7-8 Months	9-10 Months	11-12 Months	13-18 Months	19-24 Months	25+ Months
First Word	0-3 Months	4-6 Months	7-8 Months	9-10 Months	11-12 Months	13-18 Months	19-24 Months	25+ Months
2-3 Words	0-3 Months	4-6 Months	7-8 Months	9-10 Months	11-12 Months	13-18 Months	19-24 Months	25+ Months

Please describe your child's symptoms. *

	Never or Rarely	Occasionally	As expected for a child this age	Somewhat more than expected	Very frequently
Diarrhea	Never or Rarely	Occasionally	As expected for a child this age	Somewhat more than expected	Very frequently
Stomachache	Never or Rarely	Occasionally	As expected for a child this age	Somewhat more than expected	Very frequently
Vomiting	Never or Rarely	Occasionally	As expected for a child this age	Somewhat more than expected	Very frequently
Headache	Never or Rarely	Occasionally	As expected for a child this age	Somewhat more than expected	Very frequently
Constipation	Never or Rarely	Occasionally	As expected for a child this age	Somewhat more than expected	Very frequently
Earache	Never or Rarely	Occasionally	As expected for a child this age	Somewhat more than expected	Very frequently

Does your child have a history of ear infections? If yes, please describe the frequency and how the ear infections have been medically treated. *

Please describe the frequency (i.e. monthly, every 2 months, etc.) and how the ear infections have been medically treated.

Does your child have any allergies? If yes, please list what your child is allergic to, how these allergies are medically managed, and what behaviors are exhibited (if any) that may be related to allergies or the allergy medication. *

Does your child currently take medications? If yes, please list the medications, dosages, and the medical condition for which the medication is used. Also, please explain any behaviors you child exhibits that may be attributed to the medication. *

What services have you used concerning your child? *

If you checked any boxes in the previous section, please provide the name, address and phone number of the service provider. *

What is your child's current grade? *

What is the name of the school your child attends? *

What is your child's Teacher's Name? *

Has your child had formal evaluations or testing? If so, please explain the results and when the evaluation or testing took place. *

In your own words, describe any motor coordination concerns you have for your child. Include activities related to sports and self-care. *

In your own words, please explain any speech and language concerns you have for your child. Please describe your child's communication. *

In your own words, please describe your child’s balance skills. *

What are your child's strengths? *

What are your concerns about your child? *

Please share any concerns mentioned by teachers, doctors, or other professional staff. *

What do you hope will be gained by having your child seen at this clinic? *

Please upload a picture (front & back) of your insurance card.

Blue Cross Blue Shield (BCBS)	Aetna
United Health Care	Tricare
Humana	Health Net
Other Other

Pre-Kindergarten	Kindergarten	1st Grade
2nd Grade	3rd Grade	4th Grade
5th Grade	6th Grade	7th Grade
8th Grade	9th Grade	10th Grade
11th Grade	12th Grade	Other Other