Intake informationWhat type of therapy are you looking for? Occupational TherapyPhysiotherapyPsychologyNutritionOtherHave you received therapy before? Yes and I have discharge reportsYesNoDo you have a diagnosis provided by a doctor? If so, please provide your diagnosis(s) below:Do you have concerns in any of the following areas? Please check all that apply.Activities of Daily Living (bathing, dressing, grooming, tolieting, etc.)Instrumental ADLs (money management, transportation, meal preparation, medication management)Home Safety/AccessibilityFallingCognition (memory, decision making, judgement, etc)Play SkillsSocializationFeedingFine Motor Skills (writing, scissor skills, picking up small items, etc.)Gross Motor Skills/MobilitySelf Regulation (e.g.- too hyper, too calm, inability to focus, emotional highs and lows)What are your main areas of concern? Contact InformationName: City: We provide services to Airdrie & Surrounding areas, travel fees may apply to some areas.Phone Email How did you hear about us? WebsiteReferrer's website (e.g.- ACOT, Children's Link, etc.)FacebookOther social mediaReferred by friend or familyOther VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
