Trellis Occupational Therapy, PLLC | SimplePractice

Trellis Occupational Therapy, PLLC Send Message

Your info

First name

Last name

Email

Phone

Child's age

(Please include years and months for children under age 5.)

Your relationship to the child

In what city or ZIP code would services primarily take place?

(If services are requested at a school or daycare, what is the name of the school or program?)

Client's info

Is the client a minor?

Yes No

First name

Last name

Email

Phone

Child's age

(Please include years and months for children under age 5.)

Your relationship to the child

In what city or ZIP code would services primarily take place?

(If services are requested at a school or daycare, what is the name of the school or program?)

Reason for care

What would you like occupational therapy to help your child with?

Select all that apply.

Attention, planning, or executive functioning Sensory processing or sensory regulation Emotional regulation, behavior, or "big reactions" Fine motor skills Pre-writing or handwriting Gross motor coordination, balance, or motor planning Feeding or mealtime participation Dressing, toileting, grooming, or other daily living skills Play or social participation School or daycare participation Transitions and daily routines Parent or caregiver coaching Other Not sure and would like guidance

What types of services or settings are you interested in?

Select all that apply.

OT in the home OT in the school or daycare Teletherapy Parent or caregiver coaching Occupational therapy in a community setting, such as a park, library, or store Evaluation or consultation only Not sure and would like guidance

Is your child currently receiving, or have they previously received, occupational therapy?

Select all the apply:

Currently receives OT through a school or daycare Currently receives OT through a private practice, clinic, hospital, or home-based provider Previously received OT, but is not receiving it currently Has never received OT Not sure

Is your child currently receiving any other services or supports?

Select all that apply: (This helps Trellis understand your child’s current support team.)

Speech-language therapy Physical therapy Counseling or mental health services School-based EC, IEP, or 504 supports Developmental or behavioral services Early intervention services Feeding therapy Play Therapy Other None Currently Not sure

Administrative

How can Trellis best help with your inquiry?

Is there anything else you would like Trellis Occupational Therapy to know?

You may briefly share your child’s strengths, your main concerns or goals, relevant scheduling information, or questions about services. A more detailed history will be collected during the intake process.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.