Group Intake Form

Child and Family History & References Form

Child’s Name:

Date of Birth:

Parent(s)/Guardian(s):

Email:

Phone:

Grade/School:

What are your child’s strengths & interests?

Does your child have a medical diagnosis and/or has he/she ever had a serious illness or injury?

____  No

____  Yes (please list)

Has your child received occupational or other therapy?

____ No

____ Yes ______________________Start & end dates of therapy

Does your child have any behaviors we need to be aware of? 

____  No

____  Yes (please list)

Can your child participate in small groups without 1:1 support?

____ No

____ Yes

Does your child have any allergies or food restrictions? 

____No

____Yes (please list allergies)

Can they have a snack during group?

Please provide one reference and contact number for previous group setting your child has participated in.

Name: ______________________________________        

Contact #/email_______________________________

I give permission for Jill McCarthy OT to contact the reference listed above.

________________________________                        ______________

Parent or Legal Guardian                                                     Date