Occupational Therapy Intake Form Parent or Guardian's First Name*Parent or Guardian's Last Name*Phone Number*Email Address* Child's Name* What led you to seek Occupational Therapy services for your child? Please check all that apply, and describe your concerns about your child. Gross Motor: Difficulty with jumping, skipping, running, hopping Difficulty kicking a ball Difficulty throwing and/or catching a ball Appears weaker than peers, fatigues easily Avoids or has difficulty playing on playground equipment Clumsy, decreased awareness of body in space, bumps into objects and people Difficulty coordinating two sides of the body Appears stiff or awkward during movement Poor posture, frequently leans into things Awkward gait, unsteady walking, toe walking, drags feet Difficulty negotiating the stairs Concerns: Fine Motor: Difficulty with drawing, coloring, tracing Avoids drawing, coloring, tracing and/or writing Problem holding writing tools (grasp too lose, tight or awkward) Writing is too dark, light, large, or small Switches hands frequently, appears to have no dominant hand Slow in completing tabletop tasks Poor posture while sitting in a chair, leans into desk, fidgets Difficulty using classroom tools such as scissors and glue Shifts body rather than rotating across midline Concerns: Tactile/Vestibular Sensory: Avoids getting hands, face, body parts messy with paint, glue, sand, food, etc. Dislikes being close to others, hugged, and/or cuddled Craves touch Seeks putting non-food objects in mouth Seems to have decreased awareness of touch; minimal reaction to pain, food on face Picky eater, sensitive to certain textures Only wears certain clothing/avoids or dislikes other clothing Fearful of being off the ground Withdraws from touch; strong dislike of grooming activities (hair brushing/ cutting, washing) Dislikes loud sounds or is very sensitive to environmental sounds Dislikes playground equipment Avoids movement such as bouncing, swinging, rocking Decreased safety awareness and/or danger seeking Concerns: Visual/Perceptual: Difficulty copying from blackboard, workbook, or paper Loses place or omits word when reading, writing, and/or copying Reverses letters, numbers, words when reading and/or writing Complains of blurriness Appears to not be looking at what he or she is doing Trouble completing age-level puzzles Difficulty discriminating shapes, letters, numbers Difficulty copying shapes and forms Uses finger to keep place and guide movement during reading Difficulty throwing or kicking a ball at a target Concerns: Emotional/Behavioral: Does not like changes to routines Difficulty transitioning between tasks or environment Low frustration tolerance Difficulty socializing/getting along with others Is aggressive in group situations Retreats from social situations/interactions Functions better in small group or one-to-one Difficulty attending to tasks Hyperactive Impulsive Concerns: Daily Living: Difficulty manipulating zippers and/or buttons Trouble putting socks and shoes on and off Unable to tie laces (6 years and older) Difficulty dressing and undressing Difficulty with toileting Trouble washing/drying hands Difficulty brushing teeth independently Difficulty using utensils to feed self Trouble opening containers Finds household chores difficult Concerns: