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Client Questionnaire
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Client Log In
Home
About
Services
Client Questionnaire
Contact
Blog
Client Log In
Name*
Phone number *
Email Address *
What is your Primary Therapy Need and/or Health Concern?
Age Range
Adult
Child
Preferred location of my therapy appointment
My home using my computer (Virtual)
Therapy clinic/Hospital
Do you have Insurance
Yes, i have coverage
No, i have no insurance
I don't know if i have insurance
Did your Dr./Physician recommended that you receive Occupational Therapy?
Yes, my Dr. said that I need Therapy
No, I have not spoken to my Dr. about my need for Occupational Therapy servies
Are you comfortable using technology like a computer or cell phone?
Yes, using a computer or cell phone is easy for me
No, i have difficulty and require help
What do you need help with or want to improve with Occupational Therapy services?
Selfcare skills (dressing, bathing, or eating)
Adaptive equipment (obtaining shower chair, bench, toilet commode, grab bars)
Returning to work, school or leisure activities
Fall prevention, energy conservation or home safety/accessibility
pain, joint protection/orthopedic rehab
Fine motor, basic motor skills, hand strength or coordination
Caregiver or family training
Neurologic Rehab, stroke, CVA
Pain Management
Pediatrics, Sensory integration, play or handwriting
Pelvic health, Urinary Incontenence
Therapist Preference
Male
Female
No preference
What state do you live in?
Therapist Preference or any additional requests
Submit your inquiry now
Info@occupationaltherapistonline.com
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