Pediatric Occupational Therapy/
DIR®/Floortime™ Therapy
Dear______________________,
Thank you for your interest in our occupational therapy and DIR®Floortime™services. This
packet contains forms to be completed and returned by mail or fax prior to your appointment.
Please return all forms by mail or fax one week prior to the evaluation or treatment date. If you
fax the forms, please bring the originals on the date of the appointment. If you have additional
information, such as school or therapy reports, please forward those as well. Should you have
questions about the completion of these forms, please call 713-522-8880.

Best,
The Kids Connect Occupational Therapy Team
Michelle Reed, OTR/L
Occupational Therapist/ Owner
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Attendance and Cancellation Policy
CANCELLATIONS
1. Kids Connect Occupational Therapy, L.L.C. has a 24-hour cancellation policy, with
regard to patient consultation and/or treatment sessions. Please let us know as soon as
possible if it is necessary to cancel or re-schedule your child’s session. Your advance
notice enables us to offer the available appointment time to another client who needs
extra therapy or a make-up session. We are happy to try to reschedule your child’s
appointment whenever possible. There is never a charge for canceling or rescheduling
your child’s session when adequate notice is provided, as long as you maintain a 75%
attendance rate.
2. Late cancellations and no-shows will be billed at the following rates: Late
cancellations (less than 24 hours notice) = $50.00
No-shows = 100% of the scheduled session rate
3. Cancellations well in advance may be made by e-mail, but please be sure that you
receive confirmation. Cancellations made with less than 24 hours notice should be
made by telephone voicemail (you may always e-mail in addition).
ILLNESS
If your child wakes up sick, please call no later than 9:00am on the day of your
appointment in order to avoid the late cancellation fee (max. 3 times per year). In order
to keep everyone including therapist, other children and family members well, please
keep your child home for 24 hours after the last occurrence of vomiting, diarrhea, or
fever (without medicine).
____________________
____________________
Child’s name
Date
____________________
___________________
Parent’s Name
Parent’s Signature
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Acknowledgement and Assumption of Risk
I, _____________________________ (print name) acknowledge and agree to have my
child, ___________________ (print child’s name) receive occupational therapy or
DIR®/Floortime™ services from employees or independent contractors of Kids Connect
Occupational Therapy, LLC.
I acknowledge that there is some risk inherent in the use of the therapy equipment and I
agree to assume such risk and indemnify and hold Kids Connect Occupational Therapy,
LLC harmless from any and all losses and claims for any injuries or other damages
occurring to myself, my child or our belongings.
______________________________
Signature
________________
Date
______________________________
Print Name:
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Credit Card/ Debit Transaction Processing Authorization Form
_____ Yes, I would like you to automatically charge my credit card for services rendered each
month.
_____ Yes, I would like to have my checking account debited for services rendered each month.
Card Type
Number
Exp. Date
_____ Visa ____________________________ ___________
3 digit code on back of card
________
Billing Address and Name on the card:
_______________________________________________
_______________________________________________
_______________________________________________
Number
Exp. Date
3 digit code on back of card
___________
_________
Billing Address and Name on the card:
_______________________________________________
_______________________________________________
_______________________________________________
By signing this Agreement, and marking the box noted above, the undersigned does hereby agree
that Kids Connect Occupational Therapy, LLC has the right to charge to the above identified
credit card and/or debit the account identified above any and all amounts that are owed. The
undersigned agrees that its signature on this Agreement shall be deemed its signature on any
sales charge receipt.
AGREED AND ACCEPTED: Cardholders Signature: _________________________________
Date: ______________ Print Name: ________________________
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
AUTHORIZATION TO PHOTOGRAPH AND VIDEOTAPE
I/We __________________give consent to photographs or videotaping of therapy sessions with
___________________________ (name of child). I understand that visual media can be important
learning and assessment tools and that the use of these media is an integral part therapy and continued
learning. I hereby give my full consent for my child to be photographed, videotaped, and otherwise
recorded on media during his/her during occupational therapy sessions with Kids Connect Occupational
Therapy, L.L.C.
Please check the box below to acknowledge your agreement Photography and Videotaping Policy:

Authorization to Use Photographs and Recordings: I understand that Kids Connect Occupational
Therapy may use photos and videotapes as training and/or research tools. The use of videotapes for
training may include any of the following:
o
The viewing of videotapes during clinical supervision between Kids Connect OT and
DIR® Faculty members.
o
The viewing of videotapes with family members for training purposes.
o
The viewing of videotapes for training purposes with other professionals who are interested
in the DIR® model.
o
The viewing of tapes during presentations when educating others about DIR/Floortime.
I understand that the use of videotapes is an integral part of the clinical process. I further understand
that no photograph or videotape will be released to the public or media without my express written
consent.
_________________________________
Child’s Name
Date
_________________________________
Parent’s Name
___________________________________
___________________________________
Parent’s Signature
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Consent to Release Form
I, ______________________________________ (print name) give my permission and consent
to Kids Connect Occupational Therapy, LLC and respective contractors and employees to
discuss and speak with school officials, teachers, psychiatrists, medical doctors, therapists,
insurance representatives, and other professionals regarding my child as such may be needed
in connection with the treatment and/or evaluation of such child.
In addition, Kids Connect Occupational Therapy, LLC is authorized to receive any records, files,
charts, and other documentation and information from such Third Party Professionals, and by
signing this document, the undersigned is authorizing the release of any such information that
may be held by a Third Party Professional to the Company. Any person who is provided a copy
of this document may rely on it as the undersigned’s full and unconditional consent to the
release of any and all information pertaining to the child. The undersigned further authorizes
Kids Connect Occupational Therapy, LLC to release any and all information pertaining to the
treatment and/or evaluation of the child to any Third Party Professional that may in any way be
involved in the treatment and/or evaluation of the child.
The undersigned understands that some or all of the information obtained and/or released
under this document may be protected under federal regulations including but not limited to
HIPAA. By authorizing a release of information, \ the undersigned understands and agrees that
they are agreeing to the release of such information notwithstanding the protections under
HIPPA, provided, however, it is understood and agreed that Kids Connect Occupational
Therapy, LLC will maintain the confidentiality of any information obtained and will not disclose
the same except as needed in the course of treating or evaluating the child.
____________________
_____________________
Child’s Name:
Date:
_________________________
Parent’s Name
___________________________
Parent’s Signature
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Background and Contact Information
Date
/
/
Child’s Information
Name of Person Completing this Form
Relationship to child __Mother
__Father
__Legal Guardian
__Stepmother
__Stepfather
__Other
Child’s Name
First
Date of Birth
Middle
/
/
Last
Age
Sex
Place of Birth
Family Information
Parent:
__Mother
__Father
__Legal Guardian
__Stepmother
__Other
__Stepfather
Name
Address
Home Phone
Business Phone
Cell Phone
Fax
Please circle the phone number above that is best to reach you at in an emergency
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
E-mail address
Occupation ______________________________________________________________
Business Address ________________________________________________________
Marital Status
Single
Date of Birth _______________
Parent:
Married
Separated
Divorced
Religious Preference ________________________
__Mother
__Father
__Legal Guardian
__Stepmother
__Other
__Stepfather
Name
Address
Home Phone
Cell Phone
Business Phone
Fax
Please circle the phone number above that is best to reach you at in an emergency
E-mail address
Occupation ______________________________________________________________
Business Address ________________________________________________________
Marital Status
Single
Date of Birth _______________
Married
Separated
Religious Preference ________________________
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Divorced
Name and Ages of Child’s Siblings
Name _________________________________
Age ____________________
Name _________________________________
Age ____________________
Name _________________________________
Age ____________________
Medical Information
During the pregnancy with this child, did the mother experience any unusual illnesses, conditions or
accidents? ____No ____Yes If Yes, please describe below.
Was the infant born before 37 weeks gestation?
No
Yes
If Yes, how many weeks gestation?
Were there complications during delivery? ____No ____Yes If Yes, please describe.
What was the child’s birth weight? _____________
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Did the baby have trouble breathing? ____No ____Yes If Yes, please describe.
Was the baby on a respirator? ____No ____Yes If Yes, how long ___________________
Did the baby have difficulty feeding? ____No ____Yes If Yes, please describe.
Did the baby have reflux? ____No ____Yes If Yes, please describe severity and treatment.
Did the baby have seizures? ____No ____Yes If Yes, please describe.
Did the baby have other medical problems in the first year of life? ____No ____Yes If Yes, please
describe
Please check the illnesses the child has had in the past. Also indicate the child’s age at the last
occurrence and note any hospitalization due to the illness:
Illness
Yes
No
Age
Hospitalization
Measles
____
____
____
____
Chicken Pox
____
____
____
____
Mumps
____
____
____
____
Streptococcal (Strep) Throat
____
____
____
____
Scarlet Fever
____
____
____
____
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Tonsillitis
____
____
____
____
Ear Infection
____
____
____
____
Seizures
____
____
____
____
Meningitis
____
____
____
____
Were any of these illnesses followed by noticeable changes in the child’s typical behaviors?
____No ____Yes (If Yes, please describe)
Has the child had any surgeries? Please describe…
List any medications that your child takes on a regular basis. Please include any vitamins or nutritional
supplements.
Medication
Reason for medication
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Please list your child’s doctor(s)
_____________________________________________________________________________
Name
Area of specialty
Phone number
_____________________________________________________________________________
Name
Area of specialty
Phone number
_____________________________________________________________________________
Developmental Milestones
When did your child first . . .
_____ Roll over _____ Say first word
_____ Sleep through the night
_____ Sit up
_____ Smile
_____ Babble
_____ Stand alone
_____ Take first step
_____ Crawl on hands and knees
_____ Combine 2 word phrases
_____ Toilet train (If your child is not toilet trained, please describe toileting behavior.)
Dental
Does your child have any dental problems? ____No ____Yes (If Yes, please describe)
Has your child had a dental exam? ____No ____Yes If Yes, date of last exam __________
Where was the child examined? _________________________________________________
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Vision
Does your child have any vision problems? ____No ____Yes (If Yes, please describe)
Has your child had a vision exam? ____No ____Yes If Yes, date of last exam __________
Where was the child examined? _________________________________________________
Hearing
Does your child have any hearing problems? ____No ____Yes (If Yes, please describe)
Has your child had a hearing test? ____No ____Yes If Yes, date of last exam __________
Where was the child examined? _________________________________________________
Developmental Evaluations
Has your child had the following evaluations?
Psychological/Neuropsychological ____No ____Yes
If yes: _________________________________________________________________
Name of doctor
Location of Evaluation Date
Please describe the results of the evaluation
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Occupational Therapy ____ No ____ Yes
If yes: _________________________________________________________________
Name of evaluator
Place where evaluated
Date
Please describe the results of the evaluation
Physical Therapy ____ No ____ Yes
If yes: _________________________________________________________________
Name of evaluator
Place where evaluated
Date
Please describe the results of the evaluation
Speech and language ____ No ____Yes
If yes: _________________________________________________________________
Name of evaluator
Place where evaluated
Please describe the results of the evaluation
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Date
Developmental Evaluation ____ No ____ Yes
If yes: _________________________________________________________________
Name of evaluator
Place where evaluated
Date
Please describe the results of the evaluation
Neurological Evaluation ____ No _____Yes
If yes: _________________________________________________________________
Name of doctor
Place where evaluated
Date
Please describe the results of the evaluation
Other evaluations ____No ____Yes
If yes: _________________________________________________________________
Name of evaluator
Place where evaluated
Date
Please describe the results of the evaluation
Social Information
Does your child currently attend another program ____No ____Yes
If yes, where? ________________________________________________________________
What are your child’s most enjoyable activities? _____________________________________
____________________________________________________________________________
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
What frightens your child? ______________________________________________________
___________________________________________________________________________
What do you do to comfort your child? ____________________________________________
____________________________________________________________________________
What is your child’s sleeping/napping schedule? _____________________________________
_____________________________________________________________________________
What is your child’s schedule for snack and lunch? ___________________________________
____________________________________________________________________________
What are your child’s favorite play things? __________________________________________
_____________________________________________________________________________
List the places that your child frequently visits: ______________________________________
_____________________________________________________________________________
List the important people in your child’s life and what s/he calls them: ____________________
_____________________________________________________________________________
_____________________________________________________________________________
Therapy Services
Please list the therapy services that your child currently receives including number of hours per week:
Type of therapy ________________________________ Therapist _______________________
Address ______________________________________________________________________
Phone number __________________________ Hours _____________________________
Type of therapy ________________________________ Therapist _______________________
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Address ______________________________________________________________________
Phone number __________________________ Hours _____________________________
Type of therapy ________________________________ Therapist _______________________
Address ______________________________________________________________________
Phone number __________________________ Hours _____________________________
Type of therapy ________________________________ Therapist _______________________
Address ______________________________________________________________________
Phone number __________________________ Hours _____________________________
Please describe a typical 24 hour time period for your child (i.e. - from the time they wake up, until they
go to bed including daily routines and how well they do or do not sleep.)
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Please describe your vision for your child's individual educational and emotional needs:
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com
Kids Connect Occupational Therapy, L.L.C.
805 Rhode Place, Suite 350 Houston, TX 77019
Telephone: 713-522-8880
Fax: 713-522-8881
www.kidsconnectot.com