Date *

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Please list any and all accommodations needed during school. *

Speech/Language Therapy (SLP)

Occupational Therapy (OT)

Physical Therapy (PT)

Psychological/Behavioral Therapy

1:1 Aide

Other

None

Check all that apply/that you identify with: *

Autism

ADD/ADHD

Sensory Processing Disorder

Anxiety/Emotional Disorders

Epilepsy

PANS/PANDAS

AFRID (Avoidant/Restrictive Food Intake Disorder)

Other

None

Check all areas that you wish to grow in and list any specific activities you hope to achieve. *

Core strength

Finger/hand strength

Coordination and dexterity

Hand-eye coordination

Learning new motor skills

None

Check all areas that you wish to grow in and list any specific activities you hope to achieve. *

Adaptable thinking

Planning

Self-monitoring

Self-control

Working memory

Time management

Organization

None

Check all areas that you wish to grow in and list any specific activities you hope to achieve. *

Processing tactile (touch) information

Processing auditory (sound) information

Processing visual (sight) information

Processing gustatory (taste) information

Processing olfactory (smell) information

Processing proprioceptive (position in space) information

Processing vestibular (movement) information

Processing interoceptive (inside the body) information

None

Check all areas that you wish to grow in and list any specific activities you hope to achieve. *

Mindfulness and self-compassion

Environmental modifications

Breathing and movement strategies

Self-awareness and self-reflection

Emotional boundaries e.g. anger management

None