Intake Form

Is your child toilet-trained?

Yes

No

Does your child nap?

Yes

No

Cedar Park

South Austin

Diagnosed?

Yes

No

Other existing diagnoses?

Yes

No

Are you interested in receiving Speech or Occupational Therapy from our on-site partners, CoLlab Pediatric Therapies? (Check all that apply)

Speech Therapy

Occupational Therapy

Does your child attend school?

Yes

No

Current IEP/504 Plan at School?

Yes

No

Please select any of the following behaviors that your child engages in

Aggression

Difficulty regulating emotions

Deficits in Attention OR Hyperactivity

Self-stimulatory OR Repetitive behaviors (i.e. hand-flapping, lining up objects, spinning, etc.)

Repetitive vocal/verbal behaviors

Tantrums

Self-injurious Behaviors

Rituals/Routines/Insistence on Sameness