childrenstheraplay_Patient_Group

Date*

Date

How did you hear about groups at Children’s TherAplay?*

Name of Person Completing this Form*

Relationship to Child*

Services Requested:*

Movement GroupSocial-Emotional GroupFeeding Group: *Parents required to participate in Feeding Group for Ages 5-8

Patient Name*

DOB*

[Note: Child’s age must be between 5 years and 12 years 11 months old]

Sex Assigned at Birth:*

FemaleMale

Diagnosis*

Preferred Language*

All fields required -Please email us if you need assistance completing the following medical information:

Rows	Yes	No	Not sure
My child has an *aversion/fear* of animals (dogs/horses):
My child has a *severe allergy* to dogs/horses/hay:

My child can eﬀectively communicate in a group setting:*

IndependentlyWith a little helpWith some helpWith a lot of help

Additional Comments:*

My child can transition between activities every 5-15 minutes*

IndependentlyWith a little helpWith some helpWith a lot of help

Additional Comments:*

My child requires 1:1 support to engage in therapy activities*

NeverSometimesOftenAlways

Additional Comments:*

My child gets overstimulated*

NeverSometimesOftenAlways

Additional Comments:*

My child eats food by mouth*

NeverSometimesOftenAlways

Please note if your child has a g, ng, or nj tube:*

Additional Comments:*

My child can participate in group movement games, obstacle courses, or activities*

IndependentlyWith a little helpWith some helpWith a lot of help

Additional Comments:*

My child has mobility aids:*

YesNo

Additional Comments:*

My child demonstrates actions that could place the patient or others at significant safety risk (e.g., severely aggressive behaviors, frequent hitting, biting, throwing, scratching, screaming, or elopement)*

YesNo

Additional Comments:*

My child has a medical condition with acute exacerbations (e.g., asthma flare ups, seizures, etc.)*

YesNo

Additional Comments:

Thank you for completing the Group Therapy Intake Form! We review the information in this intake to determine whether group therapy is the right fit for your child and to confirm eligibility. We may contact you if we need clarification before scheduling.

New Patient Group Therapy Intake Form