Occupational Therapy Screening Form

Your Name (required)

Your Email (required)

My child is between the ages of: (required)
0-33-56-88 +

Concerns related to my child are: (required)
Fine motor related (pencil grasp, tying shoes, using scissors)Sensory related (my child is over/under responsive to sensory information from the environment such as touch, sound, or movement; poor body awareness)Both fine motor and sensory related

My child has a relevant medical/educational diagnosis: (required)
YesNo

If yes please list

My child is struggling with these difficulties: (required)
Less than 25% of the timeBetween 25-50% of the time50-75% of the timeOver 75% of the time

The following individuals have expressed concerns over my child’s fine motor/sensory skills: (required)
DoctorTeacherMyselfFamily member (grandparents, aunts, uncles, etc.)Other

Please list a few specific examples of concerns you have:

My child has recently been evaluated: (required)
YesNo

If yes by whom and when:

My child currently receives additional services:(required)
YesNo

If yes, please provide the list of current services

My level of concerns regarding my child’s fine motor and/or sensory development is: (required)
Minimal, I am not overly concernedMarginal, I am somewhat concernedUrgent, I am very concerned

Please list the best dates/times for us to call: (required)