Youth in Motion OT - Appointment Request

Welcome to Youth in Motion OT, and thank you for your interest!

To help us get a better understanding of your child’s needs, please complete the form below and we will be in contact within 24-48 hours.

The form is completed through Colib, a secure platform that states it meets Ontario PHIPA and Canadian privacy requirements.

Thank you, we look forward to learning more about how we can support your child.

Contact information

Practitioner *

Alyssa Ament OT Reg. (Ont.) Karsen Roy OT Reg. (Ont.) William Tran OTA- Hoop Pals No Preference in Provider (Increased availability)

Please answer this question.

I am interested in *

Pickle Pals 1:1 Pickle Pals Group Based OT In-Home OT Services

Please answer this question.

Child's Name *

Child's Birth date *

Caregiver's Phone number *

Email *

Referral Source *

Google Search Friend/Family Advertisement Other

Please answer this question.

Appointment request

Thank you for your interest in our practice!

What day(s) of the week is it easier for you to come for an appointment? *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Please answer this question.

What time of the day is usually better for you? *

Morning Lunch time Afternoon Evening

Please answer this question.

What is the reason of your visit? *

OT Goals *

Fine Motor: Pencil grasp scissor skills fasteners (buttons/zippers) Gross Motor: Balance coordination riding a bike core strength Sensory Processing: Sensitivity to noise clothing textures picky eating or Self-Care: Toileting dressing grooming and sleep hygiene Social/Emotional: Transitions emotional regulation and play skills Executive Functioning: Following multi-step instructions organization planning time management Feeding & Oral Motor: Sensory aversions oral mechanics self-feeding selective eating

Please answer this question.

Interests: What are your child's favourite toys, characters, or video games? *

Strengths: What does your child do well in? *

Primary Goals: "If we could accomplish three things in the next six months, what would they be?" *

Is there anything else you would like to specify? (optional)

Appointment Request - Youth in Motion OT

Thanks for requesting an appointment with our practice.

The information has been received and we will get back to you shortly.

Thanks for requesting an appointment with our practice.

The information has been received and we will get back to you shortly.

Welcome to Youth in Motion OT, and thank you for your interest!

Contact information

Appointment request

Let's view your own form now