OT Intake Form

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Getting Started

BENEFICIARY

Recipient of Therapy
Name
Requested Services

RESPONDENT

Diagnosis 1 Date
If exact date of diagnosis is unknown, input only year or only month+year.
Suspected Diagnoses
Please provide details about any past hospital stays, significant injuries, and surgical procedures you have undergone. This includes emergency room visits, planned or unplanned hospital admissions, major injuries (like fractures or head injuries), and all surgical interventions, whether recent or historical. Accurate information about these events helps us in understanding your medical history more comprehensively and assists in providing you with the best possible care.
Please provide details about pregnancy/birth history, any past hospital stays, significant injuries, and surgical procedures you have undergone. This includes pregnancy complications, emergency room visits, planned or unplanned hospital admissions, major injuries (like fractures or head injuries), and all surgical interventions, whether recent or historical. Accurate information about these events helps us in understanding your medical history more comprehensively and assists in providing you with the best possible care.
Please list all medications you are currently taking, including prescription drugs, over-the-counter medications, vitamins, supplements, and herbal remedies. Include the dosage and frequency for each. This information helps us understand your ongoing treatments and manage potential drug interactions effectively.
Please detail any known allergies to food items, medications, or substances. Please specify the type of allergic reaction experienced, such as skin rashes, respiratory issues, digestive problems, or anaphylaxis. This is crucial for avoiding allergens in your treatment plan and ensuring your safety.
Please provide details on any assessments conducted, including the dates and outcomes of these screenings. It is important to note any identified issues or impairments in hearing or vision, as these could impact the beneficiary's treatment plan and learning capabilities. If the beneficiary has not undergone recent screenings or if there are concerns about their hearing or vision, please indicate this and consider recommending further evaluation.
This section is designed to gather information about any significant medical conditions or diagnoses present in your family. Understanding your family's health history helps us identify potential hereditary risks and tailor preventive healthcare strategies. Please include any known medical conditions affecting your immediate family members (parents, siblings, children) and extended family members (grandparents, aunts, uncles, cousins) if applicable.

Legal Guardian 1

Legal Guardian 1
Legal Guardian 1 Residence
Other Current or Prior Therapies
This section aims to gather information about the child’s preferred toys, interests, activities, and hobbies. Understanding what engages and motivates the child is essential for creating a supportive and effective evaluation and treatment environment. This information helps in tailoring interventions and interactions to the child's preferences, enhancing engagement and cooperation during sessions.

Other

Primary Modes of Communication
Does you child exhibit any of the following behavior?
Sleep Habits

Availability for Therapy

This section is intended to collect information regarding the family's scheduling preferences and availability for therapy sessions. Understanding the family's schedule helps in efficiently planning and coordinating sessions. Additionally, knowing any upcoming extended unavailabilities (e.g., vacations, family events) ensures continuity of care and helps in planning breaks or adjustments in therapy as needed. Please include information on preferred days and times, constraints or limitations, upcoming extended unavailability, preferred locations for sessions, transportation issues, etc. Note that sessions are scheduled by default in our Lerncenters. However, services are also available via telehealth within limits of funding sources and clinical recommendations and in-home within limits of staff availability and clinical recommendations. Note that clinical recommendations vary widely from individual to individual, with recommendations for OT and SLP typically ranging from 1-2 hours per session, once to a few times per week, and for ABA ranging from 2-8 hours per day, 1-5 days per week.

This section aims to gather information about your family's scheduling preferences and availability for therapy sessions. By understanding your schedule, we can efficiently plan and coordinate sessions to best fit your needs. Additionally, being aware of any upcoming extended unavailabilities, such as vacations or family events, allows us to ensure continuity of care and to make necessary adjustments or breaks in therapy.

Please provide the following details:

  • Preferred days and times for sessions
  • Any constraints or limitations (e.g., school or work schedules, other therapy sessions)
  • Dates for upcoming extended unavailability
  • Preferred locations for sessions (e.g., Lerncenter, home, other)
  • Transportation issues or concerns, if any

Please note that sessions are typically scheduled in our Lerncenters. However, we also offer services via telehealth, subject to the limits of funding sources and clinical recommendations. In-home services are available depending on staff availability and clinical recommendations.

It's important to note that clinical recommendations for therapy frequency and duration vary significantly based on individual needs. Typically, OT and SLP sessions range from 1-2 hours per session, once to several times a week. ABA therapy, on the other hand, may range from 2-8 hours per day, 1-5 days per week, depending on the individual's requirements.

Contact Information

Click or drag a file to this area to upload.
Please upload any reports that might be useful for assessment and treatment planning, including diagnostic reports, school reports, and therapy reports.

Support Request

Checkboxes

Team Portal

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