Sensory Intake Form

PLEASE READ

Please add the child's name and DOB at the bottom of the waiver. This option is under participant. The signee does NOT need to be added as a participant. If there are any questions call our office at 530-780-5559

First and Last Name*

please inter the name of the FIRST participant and fill in the information below

Taste*
Prefers crunchy foods (i.e. chips, apples, goldfish)
Prefers soft foods (I.e. applesauce, grapes, hot dogs)
Strong aversion to certain foods or textures
Strong preference to specific foods or textures
Eats or chews items not considered food
Prefers bland food
Prefers heavily flavored food
Only eats familiar food
No sensitivities or concerns at this time

Please mark all sensitivities regarding taste and textures of foods. Mark "Other" box to fill in any additional concerns regarding food, taste, or textures.

Oral Motor*
Eats or chews items not considered food (I.e. chews their shirt, attempts to eat items from the yard)
Seeks hard foods or foods that require heavy chewing (i.e. peanut butter, chewing gum)
Enjoys doing large facial movements (i.e. big smiles, puckering lips)
Seeks input to mouth (i.e. brushing teeth or electric toothbrush, utilizing a sucking sippy cup past age appropriate)
Avoids sensory input to mouth
No sensitivities or concerns at this time

Please note all applicable sensitivities regarding Oral Motor input. Mark "Other" box to fill in any additional concerns regarding oral motor input.

Smell*
Seeks strong, unpleasant smells
Avoids strong, unpleasant smells
Seeks strong, pleasant smells
Avoids strong, pleasant smells
Gravitates to one or some favorite smells
Sudden onset of certain smells or strong smells causes a tantrum or meltdown
Indifferent to scent
No sensitivities or concerns at this time
Other

Please mark all sensitivities regarding smells. Mark "Other" box to fill in any additional concerns regarding sense of smell.

Movement Processing*
Afraid of heights
Enjoying movement or constant movement
Disliking movements of escalators or elevators
Frequent tripping or bumping into things
Frequent tripping or bumping into things
Caution when using stairs or other balancing movements (i.e. standing to sitting in preparation for a slide)
Becomes dizzy easily
No sensitivities or concerns at this time
Other

Please mark all sensitivities regarding processing movement. Mark "Other" box to fill in any additional concerns regarding movement.

Visual Processing*
Seeks bright, colorful places
Avoids bright, colorful places
Becomes frustrated when unable to find something in a pile of items (i.e. finding a blue square lego in a box of legos)
Requires limited distractions to focus
Bothered by unsteady or fast movement in surrounding areas, including on TV
Not noticing others in the room
Missing safety signs or other visual cues for safety
No sensitivities or concerns at this time
Other

Please mark all sensitivities regarding visual stimuli. Mark "Other" box to fill in any additional concerns regarding vision.

Please complete the following information if you have 2 people with concerns

If not, skip to the end to complete form. Thank you!

First and Last Name

please inter the name of the SECOND participant and fill in the information below

Taste
Prefers crunchy foods (i.e. chips, apples, goldfish)
Prefers soft foods (I.e. applesauce, grapes, hot dogs)
Strong aversion to certain foods or textures
Strong preference to specific foods or textures
Eats or chews items not considered food
Prefers bland food
Prefers heavily flavored food
Only eats familiar food
No sensitivities or concerns at this time

Please mark all sensitivities regarding taste and textures of foods. Mark "Other" box to fill in any additional concerns regarding food, taste, or textures.

Oral Motor
Eats or chews items not considered food (I.e. chews their shirt, attempts to eat items from the yard)
Seeks hard foods or foods that require heavy chewing (i.e. peanut butter, chewing gum)
Enjoys doing large facial movements (i.e. big smiles, puckering lips)
Seeks input to mouth (i.e. brushing teeth or electric toothbrush, utilizing a sucking sippy cup past age appropriate)
Avoids sensory input to mouth
No sensitivities or concerns at this time

Please note all applicable sensitivities regarding Oral Motor input. Mark "Other" box to fill in any additional concerns regarding oral motor input.

Smell
Seeks strong, unpleasant smells
Avoids strong, unpleasant smells
Seeks strong, pleasant smells
Avoids strong, pleasant smells
Gravitates to one or some favorite smells
Sudden onset of certain smells or strong smells causes a tantrum or meltdown
Indifferent to scent
No sensitivities or concerns at this time
Other

Please mark all sensitivities regarding smells. Mark "Other" box to fill in any additional concerns regarding sense of smell.

Movement Processing
Afraid of heights
Enjoying movement or constant movement
Disliking movements of escalators or elevators
Frequent tripping or bumping into things
Frequent tripping or bumping into things
Caution when using stairs or other balancing movements (i.e. standing to sitting in preparation for a slide)
Becomes dizzy easily
No sensitivities or concerns at this time
Other

Please mark all sensitivities regarding processing movement. Mark "Other" box to fill in any additional concerns regarding movement.

Visual Processing
Seeks bright, colorful places
Avoids bright, colorful places
Becomes frustrated when unable to find something in a pile of items (i.e. finding a blue square lego in a box of legos)
Requires limited distractions to focus
Bothered by unsteady or fast movement in surrounding areas, including on TV
Not noticing others in the room
Missing safety signs or other visual cues for safety
No sensitivities or concerns at this time
Other

Please mark all sensitivities regarding visual stimuli. Mark "Other" box to fill in any additional concerns regarding vision.

Signee Information

PLEASE READ

Please complete the following information if you have 2 people with concerns

Please enter participants' full names: