Tests Administered: Grasping and Visual Motor Integration sections of Peabody Developmental Motor Scale, HELP Checklist, (Sensory Profile if Sensory Processing was a major initial concern), Clinical Observation and Parent Report.
Medical History: (Name) was evaluated on (this noted date) at (location) to determine need for occupational therapy services through the CPSE program. Describe medical and developmental history. See Psychosocial Report for detailed social history.
General Behavior: (Name) presented as ...describe behavior during evaluation and any parent concerns relating to behavior.
Sensory Processing: Sensory processing relates to how an individual uses his or her senses to process information from his or her surroundings, interpret this information, then provide an adaptive response. Sensory information can be received through the following systems: tactile (touch), vestibular (movement of head in space), proprioceptive (muscles and joints), gustatory (taste), olfactory (smell), visual, and auditory.
(Name) ...describe sensory processing as seen during evaluation, parent concerns, and results of Sensory Profile if administered.
Fine Motor and Visual Motor: Fine motor and visual motor performance were formally assessed by the Peabody Developmental Motor Scale. The two domains that were tested by this evaluator were "Grasping" and "Visual Motor Integration." (Name)'s raw score for the Grasping section was a , ranking him in the th percentile, performing at an age equivalent of months, which is a % delay. The raw score for the Visual Motor Integration section was , ranking him in the th percentile, performing at an age equivalent of months, which is a % delay.
Gross Motor: Describe general impressions. See Physical Therapy report for more detailed gross motor assessment.
Goals: Write CPSE OT goals if services are approved.
Upon completion of the evaluation, this clinician's initial impressions & recommendations were discussed with the caregiver. Any questions and concerns regarding the evaluation & the child's development were addressed. The caregiver agreed with the findings & recommendations offered by this clinician. The caregiver stated that the child's general performance & behavior were typical on this day.
The provision of the related services recommended above will be determined at the CPSE district meeting.
I work in a pediatirc therapy clinic and would LOVE to have you share your templates. My e-mail address is mharlan@gmail.com. Thank you!
I am just now starting a school based practice after years in Early Intervention. I would love a copy of the evaluation template if someone could email it to me. Thanks for sharing resources it's a tremendous help!
Hi Lindsey, Do you still have the copy of the pediatric evaluation form. If you do can I please have a copy? I need a template that can speed up the amount of time I spend writing evaluations.
I was searching online for sample evaluation formats to update what I am presently using. I know your post was a while ago but was hoping this would still reach you. You are very generous to offer your templates. If it is at all possible that you send your templates to me I would be so grateful. Thank you so much.
Please send me your email and I can send you many educational templetes.
I'm trying to revamp my early intervention evaluation form and would love to see what another practitioner is currently using. I was doing more EI treatments and now am beginnng to evaluate more often.
Thanks for sharing your resources it is greatly apprecaited!
My email is lkinkadeot@aol.com. Any forms you are willing to share would be greatly appreciated!