Occupational Therapy Intake Form



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Transcription:

Occupational Therapy Intake Form Child s Name: Date: Age: DOB: Gender: Address: City: Zip: (cell): Phone (home): Insurance Who referred you? Primary Care Physician Address: Member ID: Phone: 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? How are you dealing with the child s behavior/issues that brought you here? Do you feel the child is at risk for self harm or harm to others?

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dying Hurts self Difficult to console/soothe Sexual acting out Problems with authority Oppositional/defiant Mood swings Withdrawn Overly sensitive Low energy/fatigue Trauma Separation anxiety Biting Setting fires Cruel to animals Developmental delay Other: 2

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: Walked: First words: Combined words: Crawled: Slept through the night: Said Mama/Dada: 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: Rate the child s current health: Excellent Good Fair Poor Other: Has the child been hospitalized: Y N If YES, describe: How many times in the hospital: 3

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 Physical Therapy Services Speech Therapy Services Other therapy Services 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 Chronic diarrhea Constipation Other: 4

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: Judge: CASA: Attorney: Phone: County: GAL: Next Court Date: SIGNATURES Copy of DHS paperwork identifying that the child is in custody: Y N Copy of guardianship/adoptive paperwork: Y N Parent/Legal Guardian s signature Date Jennifer Moyano, OTR/L Date 5

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