Schedule A 20-minute complimentary call

Thank you for signing up for the summer session! Please fill out this form at your convenience.

Child's Name

First Name

Last Name

DOB

Parent's Name

Address/Phone

Pediatrician and/or Specialist name and number:

Has child received testing or diagnosis from any other professionals previously?

Do you or school have any concerns about the following: (please explain)

Activity Level: Too high? Too low?

Impulse control?

Attention/focus/organization?

Social behaviors/peer relationships?

Ability to communicate emotions effectively?

Mood regulation?

Falling and/or staying asleep?

Fine motor skills (cutting, writing, pre-handwriting, grasp, coloring, etc)

Gross motor skills (jumping, skipping, running, ball skills, etc)

Balance (falls or trips frequently, standing on one leg, falls out of chair)

Energy level (tires easily, more fatigue than peers)

Visual complaints (eyes tired, blurry vision, complains of bright lights)

Auditory complaints (complains of loud noises, covers ears frequently, or seems to hear every noise not noticeable to others)

Meltdowns/tantrums? (how many per week on average)

Any other concerns:

List your child’s top 3 strengths:

List your top 3 goals for your child’s sessions: