Sandbox Clinic

Client Name *

Phone *

Email *

Child's Legal Name *

Child’s Nickname

Date of Birth *

Current Age *

Gender *

Religion *

Child's Address *

Current Medical Information

Diagnosis *

Precautions *

Medications

Services Currently Accessed *

Assessment Report

Referred By *

Profession *

Clinic Address *

Contact Information *

Father Details

Father's Name *

Father's Email *

Father's Contact *

Father's Occupation

Father's Address *

Same as child’s address

Father is the guardian

Mother Details

Mother's Name *

Mother's Email *

Mother's Contact *

Mother's Occupation

Mother's Address *

Same as child’s address

Mother is the guardian

Guardian Details

Guardian's Name *

Guardian's Email *

Guardian's Contact *

Guardian's Address *

Guardian's Relation *

Child's Routine and Environment

Birth Order *

Main Companion *

Primary Language *

Family Circumstances *

Yes

Usual Weekday Routine

Activity Name *

Activity Companion *

Activity Setting *

Usual Time *

Household Members

Member Name *

Household Gender *

Male

Female

Household Age *

Household Relation to the Child *

Child Educational Background

Current School *

Grade Level *

Year Attended *

School Address *

Previous School *

Grade Level (Previous School) *

Intervention Services Received

Type of Intervention *

Session Frequency *

Intervention Period *

Center/Provider *

Documentation Received *

e.g., OT Report, Speech Therapy Report

Submit Report

Completed By *

Relation to the Child (Sign) *

Date & Time Signed *

Client Status *

New Client

Submit

Sandbox Clinic Intake Form

Current Medical Information

Father Details

Mother Details

Guardian Details

Maternal Medical History

Pregnancy Risks and Complications

Child’s Medical and Developmental History | Developmental Milestones

ADL Skills | Daily Self‑Care Tasks: Dressing

ADL Skills | Daily Self‑Care Tasks: Toileting

ADL Skills | Daily Self‑Care Tasks: Eating and Feeding

ADL Skills | Daily Self‑Care Tasks: Grooming and Hygiene

ADL Skills | Daily Self‑Care Tasks: Play

ADL Skills | Daily Self‑Care Tasks: Rest and Sleep

Child’s History of Illness and or Hospitalization

Child’s Current Medical Condition and Health Status

Areas of Concern

Child's Routine and Environment

Usual Weekday Routine

Household Members

Child Educational Background

Intervention Services Received