Therapist Form for High Hopes of Old Lyme, Connecticut

Participant's Name*

First Last

Date of Birth*

MM

DD

YYYY

Diagnosis*

Medications

Visual Motor / Perceptual Motor

Sensory Processing (areas of concern / sensitivity)

Motor Skills (fine motor, motor planning)

Functional Ability & 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

Therapist Form (OT / PT)