Get Started – Sensory Speech and OT Therapy

Prospective patient information

Full name

Date Of Birth

Parent/Guardian/Family member name (if applicable)

Relationship to patient

Contact information

Phone number

Home address

Patient lives

With family In a group home Independently With partial assistance

Referrals and services

Which services are you seeking?

Speech-language therapy Occupational therapy Both

Is the patient currently receiving services elsewhere (school, ABA center, etc.)?

Yes No

If yes, please provide the name of the agency/therapist

Medical and developmental history

Medical diagnoses (e.g. ASD, Cerebral Palsy, etc.)

Date diagnosed

If yes, please describe

Is the patient currently being followed by a primary care provider? (e.g. family medicine, pediatrician, neurologist, etc.)

Yes No

If yes, please provide the name of the PCP and the hospital/clinic they’re affiliated with

Please list any current medications

Developmental milestones

Skip this section if the patient’s communication or motor difficulties began in adulthood.

Sat without support

Crawled

Walked independently

First words

Combined two words

Toilet-trained

Areas of concern

Please check all areas where you have concerns.

Communication Skills

Limited vocabulary Difficulty understanding instructions Difficulty being understood by others Stuttering or speech fluency issues Poor eye contact Echolalia (repeating back what others say) Difficulty with social interaction/play Difficulty understanding and telling stories

Fine Motor Skills

Difficulty holding a crayon/pencil Trouble with buttons, zippers, or fasteners Messy or inconsistent handwriting

Gross Motor Skills

Clumsiness, frequent falls Difficulty with stairs, jumping, or running Poor balance or coordination Delayed motor milestones

Sensory Processing

Overreacts to sounds, lights, or textures Seeks out movement (spinning, jumping) Avoids messy play or certain textures Has difficulty with transitions or new environments

Family and cultural considerations

Primary language(s) spoken in the home

Any cultural, religious, or family values you’d like us to be aware of when working with the patient?

Availability for services

Please select at least four preferred days/times for services. We will do our best to accommodate your availability.

What are your goals or hopes for therapy?

Is there anything else you’d like us to know about the patient?

Getting Started

Downloadable Forms

Please fill out the intake form below to get started

Useful Links

Contact Us

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