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Parent Intake Information
Please complete the form below. Someone will contact you within 72 business hours.
What is the reason for your request for an evaluation at Sensory Solutions?
Emergency Contact First & Last Name
Emergency Contact's Relationship to Child
Child's First Name
Child's Last Name
Child's Date of Birth
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Phone Number
Email Address
Street Address
Zip Code
City
State
Child's School
Grade in School
Child’s Physician’s or Health Care Providers and Contact Info (including Primary Care Physician)
Date of Child’s Last Medical Checkup
Child's Height
Child's Weight
Are there any medical precautions the therapist should be aware of when working with your child?
Parent 1 Age
Parent 1 Occupation
Is Parent 1 Adopted?
Parent 1 Handedness
Parent 2 Age
Parent 2 Occupation
Is Parent 2 Adopted?
Parent 2 Handedness
Sibling(s) - Age(s) Sex(es) Adopted (Y/N) Handedness (L/R)
Marital Status
If married, is your marital situation stable and positive at this time?
Which language is spoken at home?
Should we be aware of any cultural sensitivities?
Are there other individuals or family members living at home (other than immediate family)?
What are your child’s gifts/strengths?
What do you enjoy most about your child and family?
What are your child's interests and hobbies?
What are the present problems for your child at this time?
How would you describe your child’s general adjustment at home?
How does your child get along with each member of the family?
Have there been any traumatic family events in the course of your child’s development?
Have there been any major moves (city to city, country to country)?
Has your child been given a diagnoses?
CHILDHOOD ILLNESS/PROBLEMS - Has your child ever been hospitalized?
Is your child in good general health at the present time?
PREGNANCY - What kind of experience was the pregnancy for both mother and father? Planned? Complications?
Describe your experience during labor and delivery, including birth weight, length of labor, premature, forceps used, suction, delivery position, caesarean birth and reason
Was there a positive bonding experience between mother and newborn at birth?
Describe any separations from mother during first days of life
Is your child aware of their adoption?
INFANT/TODDLERHOOD - Going back to the first two years of your child’s life, what type of baby were they and please comment on feeding, sleeping and activity level
DEVELOPMENTAL MILESTONES - (Give approximate ages if remembered, or comment on anything unusual) Rolling over, Walk, Say words, Sit alone, Chew solid food, Say sentences, Crawl, Drink from a cup
Was crawling phase brief?
Was crawling absent?
Did child use a walker (rolling plastic seat)?
Experience hesitancy or delays in learning to go down stairs?
VISUAL DEVELOPMENT - Has your child experienced any problems with their eyesight or vision?
When was your child’s last visual assessment and by whom?
AUDITORY DEVELOPMENT - Has your child experienced any problems with their hearing (operations, infections, tubes)?
If yes, on ear infections what was the frequency?
SPEECH AND LANGUAGE DEVELOPMENT - How would you describe your child’s speech and language development (normal, delayed)?
How does your child primarily communicate wants and needs?
Did your child have words and/or phrases and then show regression in speech-language skills? Please describe
SENSORY AND MOTOR DEVELOPMENT - My child seems to be overly sensitive to sensory experiences more so than most people (Describe any auditory, tactile, visual, movement, taste or smell sensitivities)
My child doesn’t seem to react to sensory experiences as readily as most people (Describe any auditory, tactile, visual, movement, taste or smell sensitivities)
My child actively seeks out sensory experiences more so than most people (Describe any auditory, tactile, visual, movement, taste or smell sensitivities)
My child has difficulty differentiating sensory experiences. (ex: confuse sounds, can’t find objects in drawer or bag without looking, bumps into things) Describe
My child has trouble learning new movements
yes
no
ACTIVITIES OF DAILY LIVING - *EATING - Does your child finger feed?
does
does not
Does your child use a fork, spoon, sippy cup, regular cup, other? (Please list all that apply)
*DRESSING - Does your child assist with dressing?
does
does not
Does your child put on/take off socks, shoes, pants/shorts, shirts, or coats? (Please list all that apply)
Does your child manipulate fasteners like velcro, buttons, zippers or snaps? (Please list all that apply)
*TOILETING - Is your child potty trained?
is
is not
Is your child able to manage clothes for toileting?
is
is not
Is your child able to wash their hands independently after toileting?
is
is not
EVALUATIONS - Has your child received any previous evaluations not mentioned above? If yes, include the type of evaluation and results. If intervention was needed, please describe
How did you hear about Sensory Solutions?
What are your goals for therapy?
Submit
