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CCHMC OTPT Transition Services: Thrive

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CCHMC OTPT Transition Services: Thrive

* Caregiver first name

* Caregiver last name

* Caregiver relationship to child (i.e. mother, father, aunt, uncle, grandparent, foster parent)

* Caregiver email

* Caregiver primary phone number

Is there a second caregiver?

* Caregiver 2 Information (Name, Phone, Email, Relationship)

* Child’s first name

* Child’s last name

* Has your child been seen at CCHMC in the past?

Yes

* Has your child been seen by an outpatient occupational and/or physical therapist at CCHMC?

Yes

* Approximately when were you last seen? What were you working on in therapy?

* Interested in group treatment? Individual treatment? Both?

Group

Individual

Both

* Child’s birthday

Child's age

* Child's biological sex?

Male

Female

Intersex

Other

* Other Biological sex

* Child's identified gender?

Boy

Girl

Non-Binary

Other

* Other identified gender

* Primary language caregiver (i.e. English, Spanish, French, Mandarin Chinese, Arabic, other)

* Primary language child (i.e. English, Spanish, French, Mandarin Chinese, Arabic, other)

* Groups interested in?

Cooking and meal preparation

Self-care

Personal safety and relationships

Emotion regulation

Fitness and nutrition

Community outings

Time management and organization for school and home

Puberty

Money management

Other

* Other groups

* Which location(s) are you willing to travel to in order to participate in our Thrive programming? Please select all that apply.

Burnet Campus (Medical Office Building – MOB)

Green Township

Eastgate

Mason

Liberty

Northern Kentucky

College Hill

Anderson

Fairfield

* How did you hear about us? (OTPT clinician, OTPT rack card, DDBP Facebook page, CCHMC provider, DDBP, other)

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