Step 1 of 7 14% Child's Name Services Requested Occupational Therapy Speech Therapy Location Requested: Winchester114 South Maple StreetWinchester, KY 40391 Lexington3257 LochNess DriveLexington, KY 40517 Gender: Male Female Non-binary Child's Date of Birth MM slash DD slash YYYY Child's Address City/State/Zip PhoneParent/Guardian #1 Contact InformationName Date of Birth MM slash DD slash YYYY Relationship to Child Occupation Employer Work PhoneCell PhoneEmail Address Parent/Guardian #2 Contact InformationName Date of Birth MM slash DD slash YYYY Relationship to Child Occupation Employer Work PhoneCell PhoneEmail Address Who does the child live with? Please include all members of the home. How did you hear about us? Family Friend Doctor Other Other: Physician InformationReferring Physician Clinic Name/Address City/State/Zip PhoneReason for ReferralPrimary Care PhysicianIf different from referring physician Address City/State/Zip PhoneInsurance InformationPrimary Insurance Claims Address Customer Service Phone NumberFaxInsured's Name ID/Policy # Group # Secondary Insurance Claims Address Customer Service Phone NumberFaxInsured's Name ID/Policy # Group # Medical HistoryHas your child ever received a medical diagnosis? Yes No Who diagnosed the child, what is the diagnosis, and when did child receive diagnosis?Previous hospitalizations/surgeries/illnessesAdd more rows as needed.TypeDateDoctor Add RemovePrevious or Present Therapies (if any)Current MedicationsAllergiesDate of last hearing screening Date of last vision screening Date of last dental screening Parent/Guardian Questionnaire Developmental HistoryPerinatal History – Please describe any complications before, during, and after birthWas the child born prematurely? Yes No Gestational weeks at birth Approximate Age of Developmental Milestones:RollingSittingCrawlingWalkingFirst Word Social/Educational HistoryChild’s School Grade/Level If not school age, other group experience? (daycare, homeschool co-ops, social groups, etc.)How does your child play? prefers to play alone prefers to play with 1 or 2 others plays mostly with siblings plays mostly with adults has a lot of friends What are your child’s favorite interests? (music, shows, toys, games, etc.)Is your child able to pay attention as well as most other children his/her age? Yes No Occupational Therapy ScreeningPlease complete if scheduled for an OT evaluation or at least interested in OT services Any concerns regarding dressing skills?i.e., getting dressed/undressed, managing buttons/snaps/zippers, shoe tying Yes No Please explainAny concerns regarding hygiene skills?i.e. tooth brushing, bathing, combing hair Yes No Please explainAny concerns regarding sensory processing skills?i.e tolerating sensory stimuli with sight/sound/touch/taste/smell/movement Yes No Please explainAny concerns regarding sleep or sleep routines? Yes No Please explainAny concerns regarding fine motor or gross motor development? Yes No Please explainAny concerns regarding play and/or social skills? Yes No Please explain Feeding/Eating HistoryPlease complete if feeding concerns are presentAny concerns regarding feeding and eating skills?i.e., using spoon/fork, drinking through straw, food choices, ability to chew/swallow, ability to latch during breastfeeding Yes No Please explainAny concerns about food choices?i.e., selective eater, eats only certain foods or textures Yes No Please explainPlease list your child’s current preferred foodsDoes your child have any dietary restrictions to be aware of?i.e. allergies, gluten free, dairy free, etc.Please review the following feeding concerns and check all that apply Thumb/finger sucking Messy eater Food allergies Pacifier use Limited diet Weight issues Difficulty nursing Food texture sensitivity Picky eater Reflux/Colic Drooling Choking/coughing while eating Tongue thrust History of tongue, lip, or cheek ties Sensitive gag reflex Do you have any further concerns regarding occupational therapy services? Speech Therapy ScreeningPlease complete if scheduled for speech evaluation or interested in servicesDoes the child communicate verbally or do they use a different method for communication?i.e AAC devices, sign language, etc.Is any language other than English spoken in the home? Yes No Which other language(s)? Does the child speak this language? Yes No Does the child understand this language? Which language does the child prefer to speak at home? Indicate the approximate age at which your child reached the following milestonesBabbledSaid first wordsPut two words togetherSpoke in short sentencesDid your child produce any consonant sounds in babbling by 12 months?(e.g., "mmm", "dah", etc.) Did your child produce consonant + vowel syllables by 18 months?(e.g., "doo", "buh", "no", etc.) Did/does your child produce /k/ or /g/ sounds in their babbling?(e.g., "goo", "gah", "kah", etc.) Did your child have 5 or more consonant sounds at 2 years old? Did/does your child prefer to use any specific consonant or vowel sounds over others? Does your child prefer to communicate with: gestures, words, both, or none of the above? Please answer YES or NO to the following questions:Follow simple directions? Yes No Follow multi-step directions? Yes No Answer questions (ie, yes, no, who, what, where...)? Yes No Ask questions? Yes No Understand what you are saying? Yes No Points to objects and actions easily? Yes No Responds correctly to yes/no questions? Yes No If you checked "NO" for any of the above, please explain:How well is your child’s speech understood by an unfamiliar listener?Is your child aware of or frustrated by any speech difficulties?What concerns do you have currently for speech services?PhoneThis field is for validation purposes and should be left unchanged. Δ
