Sensory Profile Clinical Assessment

Assessment intake form

Please complete the intake below so we can better understand your needs and determine the most appropriate assessment. If you are unsure which assessment is appropriate, select "I'm not sure which assessment is appropriate."

Personal information

First name *

Last name *

Preferred name (optional)

Date of birth *

Email *

Phone *

Preferred contact method *

Person being assessed

Who is the assessment for? *

Age of person being assessed *

Relationship to person being assessed (if other than yourself)

Assessment requested

Which Sensory Profile assessment are you interested in? *

Reason for assessment

What prompted you to seek a Sensory Profile Clinical Assessment? *

Sensory concerns

What sensory concerns are you currently experiencing or observing? *

Referral information

Were you referred for this assessment?

Referral source (optional)

Referring provider / clinician (optional)

Referring provider email (optional)

Additional information

Is there anything else you would like Openness With Therapy to know? (optional)

I understand that submitting this intake form is a request for a Sensory Profile Clinical Assessment and does not itself establish a therapeutic relationship or guarantee that an assessment appointment will be scheduled. I understand that Openness With Therapy will contact me regarding next steps. *

Submitting this form does not confirm an appointment. You will be contacted within 24 to 48 hours.