OCCUPATIONAL THERAPYPRIVATE CLIENT INTAKE FORMIf you have any questions, please feel free to contact us. Client Information Client Full Name * First Name Last Name Preferred Name D.O.B Age Preferred Pronoun Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Email Guardian Information Guardian Full Name First Name Last Name Phone Email Guardian D.O.B Relationship to Client Preferred Contact for Client * Client Guardian Other Prefered Contact Method * Text Email Call If you selected 'Other', please provide details of contact Name, relationship to client, email, phone and other information you think we would find useful. Service Type Services Required Assessments Treatment / Therapy Main Reason Autism / ASD ADHD Anxiety Bullying Behaviour Difficulties Developmental Delays Dyslexia Emotionally Sensitive Executive Functions Fine Motor Difficulties Gross Motor Difficulties Intellectual Learning Difficulties Neuro-psychological Play Time Skills Poor Handwriting Social Sensory-Processing Self-Care Difficulties Other Services Engaged Please list any other services you are engaged in and the name of the practice. Further Information Thank you!
