Test Form 2 -

Occupational Therapy Form

Contact

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Child's name

Child's date of birth

Child's gender

Child's NHS number

Home address

Home language

Name of parent(s) / carer(s)

Parent / carer telephone number

Parent / carer email address

Details of people living at home (e.g. parents, carers, siblings)

Main concerns

What are your hopes and expectations from Occupational Therapy?

Name of school or nursery

Did your child's school ever report concerns about your child's engagement or performance? If so, are there adaptations/accommodations in place? Please specify

Name of SENCo or key worker

Has your child been seen by or referred to any of the following professionals?

Paediatrician

Speech and Language Therapist

Occupational Therapist

Physiotherapist

Play Therapist / Counsellor

Medical Specialist

None of the above

Were there any complications with the pregnancy or birth? If yes, please give details

At approximately what age did your child achieve the following milestones: Roll

Sit

Crawl

Walk independently

Run

Say first word

Feed self

Does your child have a medical diagnosis? If yes, please give details

Do you have concerns regarding your child's hearing?

Yes

Do you have concerns regarding your child's vision?

Yes

Has your child had a history of seizures?

Yes

Has your child had a history of allergies?

Yes

Please give details and approximate dates of any illnesses, hospitalisations or serious accidents

Is your child on any medication? If yes please specify

Do you have any concerns about your child’s sensory processing? Please describe in more detail if applicable

Do you have any concerns about your child’s motor development? Please describe in more detail if applicable

Were there any difficulties with feeding during infancy?

Does your child eat a variety of food from all food groups? Is your child a selective eater, eats only certain foods or textures? Please specify

Does your child have any food allergies?

Is feeding a positive experience e.g. is your child settled during feeding or after? Is there excessive crying? If yes please give full details.

Does your child present with a change of movements/facial expressions/vocalisations during mealtime e.g. back arching, grimacing, blinking/eye widening, wet vocalisations? If yes please give full details.

When does this occur? Beginning, during or following feed/meal?

Does your child mouth objects or a pacifier?

Does your child suck their thumb/fingers?

Does your child enjoy taking a bath/shower?

Does your child resist having their teeth brushed?

Does your child have a regular sleep pattern? If not, do they struggle to fall asleep, stay asleep, or both? Do they take any sleep medication?

Does your child prefer to play/spend time alone or with others?

Is your child toilet trained?

Is your child able to dress/undress themselves independently? If so, what can they put on/take off?

Does your child appear sensitive to sounds? If so, what type of sound?

Does your child constantly make noises to him/herself?

How long can your child concentrate on a task that they like?

Does your child like playing/spending time with others?

Does your child appear ‘on the go’?

Is your child left or right handed?

Does your child fall over a lot or bump into objects often? If so please describe

Does your child seem more clumsy than other children their age?

Is your child able to use cutlery?

Does your child enjoy school? If no, do you know why not?

What are your child's main interests?

Please tick the boxes to show whether you give consent to the following:

I agree for my child to be seen for an assessment and/or therapy by The Children's Wellness Centre Occupational Therapy Team. I understand I can withdraw my consent at any time

If appropriate, I agree for any relevant information about my child to be shared between relevant professionals (e.g. school, doctor, psychologist, NHS therapist etc) in confidence, in the best interest of the child’s development

I understand that audio, video or photographic records may be made as part of my child’s assessment and therapy

I agree to the use of electronic communication. All documents will be password protected and saved as a PDF

I understand that all paperwork and notes are owned and securely stored by my child's individual Therapist in accordance with GDPR. Reports are stored by my child's individual therapist, and not stored internally by The Children's Wellness Centre

Terms and Conditions of Therapeutic Services within The Children's Wellness Centre

Please read each section carefully, including the cancellation policy.

By ticking the following checkboxes, the client is accepting the terms and conditions below

Cancellations

We have a strict cancellation policy of 48 hours, which applies to all cancellations, including non-attendance for traffic and illness. Once you have booked in a block of sessions, this space is saved just for you, and the therapists carry out a substantial amount of work each week planning for each individual session.

We do appreciate that you will not always be aware of last minute illnesses, however if we have any cancellations less than 48 hours prior to each session, this means the therapist will have prepared for the session and unfortunately the fee is still due.

The 48-hour cancellation policy applies to the time of day your session is booked for; for example, if your session is booked for 10.00am on a Wednesday, you must notify us of your planned absence by 10.00am on the Monday, in order not to be charged.

We plan 48 hours in advance of each session, and by following this, this will ensure your therapist does not plan for your session in advance, and therefore no fee is due.

The cancellation policy is in place to ensure the longevity of the clinic and to ensure we can continue to provide services to families. When we receive multiple last minute cancellations, which does often happen, all the clinic costs still apply, in terms of having to pay the therapist for their planning time as well as the reception team who are booked in depending on the number of sessions planned for each day. If no cancellation fee is charged, the clinic will not be able to remain open long term, and we will not be able to continue supporting the high numbers of children in need, each week.

To cancel a session please contact your individual therapist within 48 hours of your session date and time.

I am aware of the cancellation policy. I am aware this also applies to last minute illnesses and if I do not give 48 hours' notice for my session cancellation, the full fee is still payable.

Our Therapists will adopt a client-led approach and will offer advice, support and options for next steps, but it is the client's responsibility to decide what is right for their child

The Therapist that you are seeing is DBS checked and holds Professional Indemnity insurance, practicing within the framework of their profession and registrations

The Therapist reserves the right not to accept a referral, terminate an assessment or not to circulate an assessment report if the referral appears to be outside their area of expertise or the client fails to comply with the terms and conditions set out in this agreement. The Therapist reserves the right not to provide therapy sessions for a child after an assessment has been carried out, if in the best interests of the child they feel that the therapy sessions would not be clinically appropriate or beneficial to the child

Payment for Occupational Therapy Assessments is required at the time of booking, to secure the space and is only confirmed on receipt of paperwork and the necessary paperwork

Payment for weekly therapy sessions is due the day before each session. Clients will be sent an email invoice each week and payment is made by bank transfer

For any clients claiming through their health insurance, payment must be settled directly with The Children's Wellness Centre by the client and can be reclaimed via their insurance provider, using the receipt we can provide

I confirm I have read The Children's Wellness Centre policies (Privacy, Information Sharing, Confidentiality, Complaints, Zero Tolerance, Covid-19 and Illness policies), accessed via the policies page

I can confirm I have read The Children’s Wellness Centre full terms and conditions found at https://childrenswellnesscentre.co.uk/terms-conditions/

Occupational Therapy Form

Terms and Conditions of Therapeutic Services within The Children's Wellness Centre

Cancellations

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