KIDS OT Services Intake Form

A. REQUESTER INFORMATION (Individual filling out this form)
B. MAIN CONTACT
C. SERVICE REQUESTED
D. CHILD/CLIENT INFORMATION & BACKGROUND
E. MEDICAL HISTORY
F. HEALTH CARE PROVIDERS
G. COMMUNICATION
H. EDUCATIONAL INFORMATION
I. EARLY YEARS DEVELOPMENTAL MILESTONES
J. ACTIVITIES OF DAILY LIVING (Please select the choice that best describes the current level of assistance required for the child to complete each task)
K. BEHAVIOUR AND SOCIALIZATION
L. SENSORY PROCESSING - please check the boxes for any areas in which you suspect or know that the child processes sensory information differently
M. CREDIT CARD/BILLING INFORMATION - Please note that we accept payment by credit card, cheque (businesses only) and e-transfer
N. OTHER