Client Forms

Prior to your appointment, please download and fill in the client questionnaires and forms below and mail to:

Miriam Manela
Thrive Occupational Therapy
68 Ascension Street
Passaic, NJ, 07055

Alternately, you may email them to: miriam@otthrive.com or fax them to 973-828-8034. We may request that you fill in other questionnaires if we feel they will help us understand your child better.

Please Note: It is best if I receive your completed questionnaires 48 hours before an appointment. I use these to assess the client through the eyes of his/her caregivers.

These assessments also help me understand the functional difficulties that your child may be experiencing on a daily basis, and the unique, underlying contributing factors.

The few minutes invested in filling out these forms are important to your child’s success in therapy.

Please go to our appointment page for additional information about making an appointment. (The client forms are also posted on our appointment page).


CLIENT QUESTIONNAIRES AND FORMS

  1.  WELCOME LETTER
    Please read the WELCOME LETTER. Also, please place your initials next to each paragraph and sign and date at the end of the document.
  2. THRIVE QUESTIONNAIRE
    Please fill out the  THRIVE QUESTIONNAIRE by circling all statements that the client has difficulty with and the issues that you would like addressed during therapy. If some issues are priorities for you, please prioritize by using numbers in the circles instead of checks. If you’d like to do this with your child (assuming he is old enough to be part of the process), please use two different color pens, one for your priorities and one for your child’s.
  3. SENSORY PROFILE
    Please call or email the office, and we will send you a Sensory Profile form.
  4. FUNCTIONAL LISTENING QUESTIONNAIRE (Ages 0-15)
    FUNCTIONAL LISTENING QUESTIONNAIRE (AGES 15 AND UP)
    Please fill out the FUNCTIONAL LISTENING QUESTIONNAIRE as thoroughly as possible.
  5. THRIVE HIPAA FORM
    Please fill out HIPAA form.