JOTS Occupational Therapy Intake Form

REASON FOR OCCUPATIONAL THERAPY EVALUATION / INTERVENTION *

When did you notice these concerns? *

Does your child have any medical diagnosis we should be aware of? *

Has your child received previous evaluation or treatment therapies? *

Does your child attend school or nursery? *

If yes, where? *

Is your child involved in clubs or extracurricular activities ? Please share. *

What are your child’s interests at this time ? What do you consider his/her strengths? *

BIRTH HISTORY / COMPLICATIONS (Check all that apply) *

Other complications - please explain *

Gestational weeks: *

Birth Weight: *

Medical History (Check all that apply) *

OCCUPATIONAL THERAPY BERMUDA