Therapist Form

Participant's Name*
First Last
Date of Birth*
Month
Day
Year
Diagnosis*
Medications
Visual Motor / Perceptual Motor
Sensory Processing (areas of concern / sensitivity)
Motor Skills (fine motor, motor planning)
Functional ability and reflex limitations
Sitting, balance (include static/dynamic surfaces)
Behavior
Safety Awareness
Therapy Goals
Successful Intervention Strategies used (sensory modalities, behavioral, rewards, etc.)
Primary Therapist Signature (Please type your name to sign)*
Therapist Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Today's Date
MM slash DD slash YYYY

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