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Welcome to Sandbox Clinic BGC Intake Form.

Please take a few moments to provide the information below. Your responses help us understand your child’s needs, strengths, and background so we can offer the most appropriate support and care. All information shared will be treated with respect and confidentiality.

Child’s Profile
Current Medical Information
Parent Details
Guardian Details


Maternal Medical History
Pregnancy Risks and Complications
Child’s Medical and Developmental History | Developmental Milestones

(2-3 months)

(4-6 months)

Sitting without support (6-8 months)

Walking with assistance (9-12 months)

First words (12-18 months)

(12-15 months)

Putting 2-3 words together (18-24 months)

(24-36 months)

ADL Skills | Daily Self‑Care Tasks: Dressing

Can your child put on and put off clothes independently?

Can your child identify what to wear depending on the occasion?

Can your child manipulate buttons (buttoning and unbuttoning?)

Can your child manipulate a zipper?

Can your child identify where to put body parts on the holes of the clothing?

Can your child recognize correct and incorrect orientation of clothes?

ADL Skills | Daily Self‑Care Tasks: Toileting

Can your child recognize the sensation when they need to go to the toilet?

Can your child indicate the need to go to the toilet?

Can your child sit independently on the toilet seat?

Can your child go to the toilet independently?

Can your child manipulate their clothing before and after toilet use?

Can your child recognize peeing from pooping?

ADL Skills | Daily Self‑Care Tasks: Eating and Feeding
ADL Skills | Daily Self‑Care Tasks: Grooming and Hygiene
ADL Skills | Daily Self‑Care Tasks: Play
ADL Skills | Daily Self‑Care Tasks: Rest and Sleep
Child’s History of Illness and or Hospitalization
Child’s Current Medical Condition and Health Status
Areas of Concern
Child's Routine and Environment
Usual Weekday Routine
Household Members
Intervention Services Received
Completed By and Date Signed
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