Therapy Clinic Intake

The Saul and Toby Feldberg & Family Therapy Centre at KCC provides a child-centric, multidisciplinary approach to paediatric care to help your child reach their full potential. Our team of experts will assess your child’s needs and develop an individualized care plan that addresses all areas of development.

Please note, our centre is closed on Saturdays.

Fill out the form below, and our clinic administrator will be in touch to determine the best approach for your child.

Name of Parent/Guardian Completing Form(Required)

First Last

Relationship to child(Required)

Child's Name(Required)

First Middle Last

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Preferred Name and/or Pronunciation

First

Mother's Name(Required)

First Last

Father's Name(Required)

First Last

Has your child or anyone else in your family attended KCC programs or services?(Required)

Currently enrolled

Previously enrolled

Never

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Child's Date of Birth(Required)

Child's Age

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Child's Gender(Required)

Languages spoken at home(Required)

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Family Context (siblings and ages, other caregivers, etc.)(Required)

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Current program or school & grade(Required)

Services of Interest(Required)

Infant Early Intervention (under 2 years old)

Physiotherapy (infant development, balance, coordination)

Occupational Therapy (fine/gross motor, sensory processing)

Hydrotherapy (PT or OT in the pool)

Infant Hydrotherapy

Trexo

Speech and Language Therapy (AAC, delayed speech, articulation)

Music Therapy

Therapy Intensives

Past or current therapies (school, clinic, etc.)(Required)

Tools for support, if used (AAC (Augmentative and alternative communication) device, hearing aids, wheelchair, walker, etc.)

Devices

No tools used for support

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Primary Physician(Required)

First Last

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Primary Physician's Phone(Required)

Country Phone Number

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Developmental Physician

First Last

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Developmental Physician's Phone(Required)

Country Phone Number

Please specify your child's diagnosis(es) (e.g. Cerebral Palsy, ASD, Down Syndrome, ADD/ADHD, learning disability, seizures, genetic disorder/syndrome)(Required)

Have you been approved for Access OAP?(Required)

Significant Medical History (hospitalizations, recent diagnosis, etc.)(Required)

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Hearing and/or Vision(Required)

Within Normal Range

Glasses

Hearing Aid

Other (please specify)

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Additional details

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Allergies (include sensitivities)(Required)

What are your main concerns?(Required)

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Safety concerns (risk of falling, choking, running/elopement)(Required)

Does your child engage in any challenging or unsafe behaviours? If yes, what are the behaviours and what are the triggers?(Required)

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Describe your child's gross motor abilities (crawling, standing, walking, jumping, stairs, catching, etc.)(Required)

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Describe your child's fine motor abilities (puzzles, using scissors, drawing, printing, etc.)(Required)

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Does your child use adaptive equipment for mobility? (Orthotics/braces, stander, walker, stroller, wheelchair)(Required)

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Sensory concerns (sensitive to touch, botherered by certain textures, limited diet, sensitive to noise, sensitive vision, etc.)(Required)

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Does your child use adaptive equipment for sensory concerns (noise-cancelling headphones, weighted equipment, etc.)?(Required)

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Please describe your child's eating (picky eater, self-feeding, gagging, choking, etc.)(Required)

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Does your child use adaptive equipment for eating? (Tube-fed, specialized bottle/cup/utensils/plates/seating)(Required)

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Describe your child's level of independence with acts of daily living (dressing, showering, toileting)(Required)

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What does your child enjoy doing? (Toys, games, pastimes, sports, hobbies, books)(Required)

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How does your child indicate what they want? (Gestures, single words, phrases, convesational, communication device, etc.)(Required)

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What do you see as your child's greatest strengths?(Required)

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What do you feel are your child's biggest challenges right now?(Required)

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Does your child engage in any challenging behaviour (agression to self/others)? If yes, what are the triggers?(Required)

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How does your child respond when frustrated or overwhelmed? What helps your child calm down?(Required)

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What is the biggest challenge your family is experiencing right now?(Required)

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What are you hoping therapy will help your child achieve?(Required)

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What do you hope your child will be able to do in the next 6 months and in 1-2 years?(Required)

Do you have anything else to add?

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How optimistic are you about your child's progress with therapy?(Required)

I expect very little change

I expect gradual improvements

I expect stead improvements in several areas

I expect my child to catch up to peers over time

I expect my child to overcome most or all of their current challenges

What is your availability?(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Sunday

What is your preferred appointment time?(Required)

Early Morning

Afternoon

After School Hours

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Please list any other questions or concerns(Required)

How did you hear about us?(Required)

Friend/Family

Doctor

Instagram

Facebook

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Other

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