The Therapy Spot

Patient Information

Patient First Name

Patient's Preferred Pronoun or nickname

Patient Last Name

Date of Birth

Age

Gender

Name of Person Completing Form

Relationship to Patient

Primary Language Spoken

Does patient live with both parents?

How did you hear about Therapy SPOT?

Scheduling Availability (Day/Time)- Please note that some days/times may have a waitlist

Which location do you prefer?

Contact Information

Mailing Address

City

State

Zip Code

Home Phone #

Cell Phone #

Work Phone #

Best Time/s to Call

Preferred Method of Communication

Home

Cell

Work

Cell phone carrier (for text reminders)

Therapy SPOT location you will be visiting

Farmington Hills

Troy

Email Address

Emergency Contact (name and relationship if applicable)

Phone #

Please list additional person(s) who will be involved with child's therapy. Name, Relationship and Phone #

Insurance

Name of Person Insured

Relationship to Patient

Birthdate

SS#

Occupation

Employer

Employer Address/Phone #

Primary Insurance

Secondary Insurance

Group Number

Contract #

Health and Medical History

Please list any known allergies

Please list any known or suspected diagnoses or medical precautions

Primary concern/reason for today's visit

Please list and medications/vitamin and quantity

Is your child currently on a special diet or have any food restrictions?

Yes

Tests/Procedures/Surgeries

Test/Procedure

Reason

Date

Results

Child was delivered:

Vaginally

C-Section

unknown/NA

Length of Pregnancy (weeks)

Days in Hospital

Birth Weight

Delivery Complications:

Complications following birth:

Name of Referring Physician

Phone #

Other Physicians and Specialists (i.e. pediatrician, neurologist, psychologist)

Type

Name

Reason

Past/Current Therapy Sessions

Type

Frequency

Location

Dates

Current?

School

Name of School

Grade

Does Child have and IEP?

Does Child receive any accommodations to be successful in school?

Please list/explain any concerns or difficulties child demonstrates in the school environment:

Development

Speech/feeding milestone

Names familiar objects

Uses 2 word combination

Uses complete sentences

Uses a bottle

Uses a pacifier

Speech/feeding milestone

Eats baby food

Eats junior food

Eats table food

Uses cup, sippy cup

Uses straw

Motor milestone

Holds head up alone

Grabs toys

Rolls over

Sits alone

Motor milestone

Creeps/crawls alone

Pulls self to standing

Walks unaided

How does child get around the house?

Does child easily lose balance or fall?

Please list child's favorite toys and/or play activities

What were child's first words?

At what age?

Speech and Feeding

Current speech concerns

How does your child communicate? (check all that apply)

Body language/facial expressions

Single words

Sentences longer than 4 words

Non-verbal

Eye gaze

Sign Language

Gesturing/pointing

Sounds (vowels, grunts)

Does your child use an Augmented Communication Device?

Does your child:

Repeat sounds, words, or phrases over and over?

Understand what you are saying?

Retrieve or point to common objects upon request?

Follow simple directions ('shut the door' or 'get your shoes')?

Respond correctly to yes/no questions?

Respond correctly to who/what/when/why questions?

Have trouble describing events or thoughts?

How much of your child's speech do you understand?

How much to unfamiliar listeners understand?

Activities of Daily Living (ADL)

Please indicate the amount of assistance your child needs with the following tasks:

Puts on shirt/pants:

Puts on socks/shoes:

Unbuttons, unsnaps, unzips:

Brushes teeth:

Toileting:

Zips jacket:

Ties shoes:

Wipes after toileting:

Bathing, washing hair:

Cuts with knife and fork:

Uses utensils during meals:

Removes clothing:

Please note any additional concerns regarding child's ability to be independent in his or her daily routine:

Goals for Therapy

Please list at least 3 goals per discipline that you hope to achieve with the help of therapy:

Additional Concerns

Additional forms are recommended based on the type of evaluation you are seeking. These forms listed below can also be completed online on our website. If you have any questions, please call our office at 248-893-6192. Please check all that apply.

I have concerns about my child's sensory processing abilities (Please complete "Sensory History Questionnaire")

I have concerns about my child's eating/feeding abilities (Please complete "Food & Mealtime Assessment")

I have concerns regarding my child's behavior (Please complete "Behavior & Regulation checklist")

None of the above apply to my child

Once this form has been submitted and our office has received the prescription from the child's doctor, we will verify insurance benefits and contact you within 1-2 business days. Incomplete intake forms may result in processing delays. Yor doctor and fax the prescription directly to our office at 248-457-5490. Please check your status below.

I have already sent or requested that my doctor send a prescription to the Therapy SPOT

I plan to submit a prescription in the next 7-10 days

I do not have health insurance (prescription not needed)

Would you like to discuss your concerns regarding your child via a phone interview? If you select yes, our staff will contact you using your contact preferences indicated at the start of this form, prior to your child's evaluation, you may also be contacted.

Yes, please contact me to discuss my concerns prior to my child's evaluation

No, I prefer to not complete a phone interview unless the evaluating therapist finds it necessary

The information provided in the form helps our therapists tailor the evaluation to meets the needs of your child, so thorough responses are appreciated. Any additional concerns or comments, please note them below:

additional