Date *

MM

DD

YYYY

Client's Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Parent/Guardian Name

First Name

Last Name

Phone

(###)

###

####

INSURANCE *

Yes

No

Choose One *

HMO

PPO

CCAH

CASH

OTHER

Name of Insured

First Name

Last Name

Date of Birth

MM

DD

YYYY

Primary Care Physician

First Name

Last Name

Phone

(###)

###

####

Do you have secondary Insurance?

*We do not bill secondary Insurances.

Yes

No

Teacher's Name

First Name

Last Name

Does your child currently receive school-based services?

Yes

No

Body, Movement, and Motor Planning:

Please check if area of concern

Motor coordination (i.e. difficulty with climbing, throwing/catching balls, jumping jacks)

Balance (i.e. frequently falls or trips)

Poor body awareness (i.e. difficulty maneuvering around furniture/people/objects without bumping into them, seems accident prone)

Poor postural/core strength

Poor body strength

Seems t o exert too much pressure for the task (slamming doors, pressing t o hard when using pencils or crayons)

Grasps objects (such a s spoon o r pencil) loosel

Difficulty with imitating body movements (songs with motion 'itsy-bitsy spider, Simon says)

Avoids movement activities or using playground equipmen

Dislikes when head i s tilted upside down

Poor endurance/tires easily (especially when standing or holding particular body position)

Gets hurt often during play / poor safety awarenes

Seeks out movement that i s unsafe and/or interferes with daily routine

Fine Motor/Visual Motor:

Please check if area of concern

Still switches hands - no hand preference/dominance

Awkward/immature grasp on marker/pencil

Avoids drawing, art, or writing activities

Poor handwriting (i.e. legibility, letter formation)

Difficulty with spacing or staying on lines when writing

Tires easily with writing activities or requires increased time to complete writing tasks

Difficulty cutting with scissors

Difficulty with manipulating small items (ie. blocks, Legos, construction projects)

Difficulty with opening containers (play dough, snacks in bags, ets...)

Feeding/Eating:

Please check if area of concern

Likes to chew on non-food items (i.e. toys, shirs)

Has difficulty manipulating food in mouth (i.e. chewing, closing lips fully, excessive drooling, gagging, chocking)

Avoids eating new foods

Needs food cooked/prepared a particular way, or only likes certain brand

Has a limited diet

Bothered by certain smells

Personal/Social – Behavior and Emotions:

Please check if area of concern

Sharing and cooperating with friends (i.e. difficulty taking turns)

Participating appropriately in outings (i.e. difficulties in going to grocery store, birthday parties, parks)

Difficulty following directions

Difficulty with transitions

Difficulty with handling unexpected changes or changes in routine

Limited variety of play interests and imagination

Limited attention when participating in tasks

Engages in repetitive and self-injurious behaviors that impede on functional performance

Self Care:

Please check if area of concern

Utensils use (i.e. forks, spoons, drinks from cup, cuts with knife)

Removing clothing, shoes

Putting clothing, shoes on

Tying shoes

Managing zippers, buttons, fasteners

Brushing hair and teeth, washes face and body

Following a 3-4 step routine/task

Organizing his/her own things, cleaning up room

Difficulties with sleeping (i.e. falling asleep, staying asleep)

Visual Processing:

Please check if area of concern

Easily distracted looking at things in the room when completing a task

Sensitive to light (prefers to be in the dark)

Difficulty finding things in a cluttered space

Tends to draw or write in reversals

Auditory Processing:

Please check if area of concern

Has speech or articulation difficulties

Seems bothered by ordinary household sounds (toilet flushing, hair dryer, vacuum)

Shows significant distress with unexpected sounds or loud noises (runs away, cries)

Appears to not hear what you say or hear name being called

Enjoys making unnecessary sounds (causing certain sounds to happen over and over again: excessively banging toys, yelling, etc...)

Has difficulty remembering directions

Has difficulty functioning/completing a task if there is a lot of noise in the room (people talking, TV, or music on)

Touch Processing:

Please check if area of concern

Excessively seeks touching people and objects

Has a high pain tolerance/decreased awareness of pain and temperature

Avoids messy textures when playing (paint, glue, sand, etc...)

Shows distress to being touched

Shows distress with certain fabrics, clothing, shoes, or bed sheets

Shows distress with brushing hair, brushing teeth, bathing, nail clipping, hair cuts

Please complete the following to allow your child to participate in snack activities:

My child may participate in snacks and has no diet restrictions.

My child may participate in snacks if diet restrictions are observed.

Diet restrictions:

My child may participate in snacks; however, I will provide his/her snack.

My child should not participate in snack time.

VIDEO AND PICTURE RELEASE

I give permission for my child's picture/video to be used by Growing Adventures for the purpose of training other professionals and paraprofessionals.

I give permission for my child's picture/video to be used by Growing Adventures for marketing/publicity.

I do not wish for my child's picture/video to be used for any purpose other than training his/her specific clinical team.

I do not wish for any photos/videos to be taken of my child.