Parent Questionnaire

Hello: Please complete the following questionnaire. In this survey, you will be asked questions about your child's habits and daily function. It will take approximately 15-30 minutes to complete the questionnaire.

You are encouraged to be as thorough as possible to provide the best plan of care for your child.

Thank you for your time and cooperation.

Please start with the survey now by clicking on the Continue button below.

Name

Child's Name (First, Middle, Last)

Are you familiar with occupational therapy?

What are your main concerns for this child?

Does your child have a formal diagnosis? If so, please indicate diagnosis(es), the date the diagnosis was given and from whom it was received.

Please list any notable medical history for you child (i.e., surgeries, injuries, etc).

Has your child ever received therapy services before?

Yes

If yes, please indicate what type of therapy and how long your child received it.

* Please indicate any allergies your child may have (food or medication). If none, please state N/A.