Therapy Evaluation
NAME:
DISTRICT:
OCCUPATIONAL THERAPY and PHYSICAL THERAPY EVALUATION
STUDENT: SCHOOL:
DOB: DISTRICT:
AGE: GRADE:
DISABILITY: TEACHER:
DATA COLLECTION DATE(S) : THERAPIST:
PHYSICIAN: Delete this section if not needed
PRECAUTIONS: Delete this section if not needed
REASON FOR REFERRAL:
SOURCES OF INFORMATION:
(label and divide into Normed, Criterion, Clinical Obs, Standardized, etc)
OT and/or PT Documentation of School Function
OT and/or PT Documentation of School Function – Modified
Adolescent Autonomy Checklist
Beery VMI 5th Edition
Callier-Azusa Scale (CAS)
Canadian Occupational Performance Measure (COPM)
Children’s Assessment of Participation and Enjoyment and Preferences for Activities for Children (CAPE) (PAC)
Children’s Handwriting Evaluation System (CHES)
Children’s Handwriting Evaluation System – Manuscript (CHES-M)
Clinical Evaluation
Clinical Observations of Motor and Postural Skills (COMPS)
Comprehensive Test of Visual Functioning (CTVF)
Denver Handwriting Analysis (DHA)
Developmental Test of Visual Perception – Second Edition (DTVP-2)
Draw a Person Test (DAP)
Dressing Screening
Erhardt Developmental Prehension Assessment (EDPA) – Revised
Erhardt Developmental Vision Assessment (EDVA)
Evaluation Tool of Children’s Handwriting (ETCH)
Handwriting Without Tears – Cursive
Handwriting Without Tears – Printing
Kohlman Evaluation of Living Skills (KELS)
Motivational Assessment Scale (MAS)
Motor Free Visual Perception Test – 3 (MVPT-3)
Observation of Hand Skills for the “K-1” Child
Observation of Handwriting Skills
Observation of Written Expression Skills
Occupational Therapy Psychosocial Assessment of Learning (OT PAL)
Peabody Developmental Motor Scales – 2 (PDMS-2)
Pediatric Evaluation of Disability Inventory (PEDI)
Preschool Visual Motor Integration Assessment (PVMIA)
The Print Tool
Quick Neurological Screening Test – Revised (QNST-II)
School Function Assessment (SFA)
Self-Help Skills Screening
SensoriMotor Performance Analysis (SPA)
Sensory Integration Inventory-Revised
Sensory Processing Observations
Sensory Processing Measure
Sensory Profile
Sensory Profile – Adolescent/Adult
Sensory Profile – Infant/Toddler
Slosson Visual-Motor Performance Test (S-VMPT)
Spatial Awareness Skills Program Test (SASP)
Test of Auditory-Perceptual Skills (TAPS)
Test of Gross Motor Development
Test of Pictures/Forms/Letters/Numbers
Test of Visual-Motor Skills – Upper (TVMS-U)
Test of Visual-Motor Skills – Revised – Lower (TVMS-R-L)
Test of Visual Perception Skills – Lower (TVPS-L)
Test of Visual Perception Skills – Upper (TVPS-U)
Review of Student Folder
Parent Interview
Student Interview
Teacher Interview(s)
Written Productivity Profile (WPP)
BRIEF (executive fx)
EASY Assessment
(FACTER)
(M-FUN)
FirstSTep
Every Move Counts(EMC)
Transdisciplinary Play Based Assessment
Schoodles
SCOPE
Bus transportation checklist
PAR
Infused Skills Assessment-LID
Functional Schema-LID
Rubric for life skills programming, etc______
Oral Motor Feeding Rating Scale,
Ecological Assessment- Downing
SETT-AT assessments
COMPLIANCE: Compliant Not Compliant Explain if not compliant
BACKGROUND DATA:
Student has a disability/diagnosis of
Previous services/history
How disability affects learning and participation
How behavior affects participation
Child's program and supports consist of
CURRENT SCHOOL OBSERVATIONS:
Present level of academic achievement and functional performance
Successful modifications currently in place
Adaptive equipment and/or assistive technology in IEP - (used or unused?) (home and/or school?)
TEST RESULTS:
Adolescent Autonomy Checklist
The Adolescent Autonomy Checklist is designed to identify the student’s knowledge of their illness and/or disability skills at home, health care skills, community skills and leisure skills. This information may be helpful in the transition process.
Summarize results
Beery VMI 5th Edition
(by Keith Beery, Ph.D.)
The Beery VMI 5th Edition is designed to assess the extent to which individuals can integrate their visual and motor abilities.. The VMI is not timed. It is standardized for normal children between the ages two years and adult. Completion of the test will provide a standard score and percentile. Supplemental, standardized Visual Perception and Motor Coordination tests are available as a means for statistically assessing visual and motor contributions to the VMI performance.
VMI Standard Score: scores Percentile: scores Scaled Score: scores
Visual component Standard Score: scores Percentile: scores Scaled Score: scores
Motor Component Standard Score: scores Percentile: scores Scaled Score: scores
Callier-Azusa Scale (CAS)
(created at the Callier Center for Communication Disorders at the University of Texas/Dallas)
The Callier-Azusa Scale (CAS) is an instrument designed for the assessment of deaf-blind, multi-handicapped children. Administration of the CAS is based on observation of behaviors which typically occur in conjunction with classroom activities.
Motor Development
Postural Control score months Fine Motor score months
Locomotion score months Visual Motor score months
Perceptual Development
Vision score months Fine Motor score months
Auditory score months Tactile score months
Daily Living Skills
Dressing score months Feeding score months
Personal Hygiene score months Toileting score months
Cognition, Communication, and Language
Cognition score months Expressive score months
Receptive score months Speech score months
Social Development
Adults score months Environmental score months
Peers score months
Canadian Occupational Performance Measure (COPM)
(by Mary Law, Ph.D., Sue Baptiste, M.H.Sc., Anne Carswell, Ph.D., Mary Ann McColl, Ph.D., Helene Polatajko, Ph.D., Nancy Pollock, M.Sc.)
The Canadian Occupational Performance Measure (COPM) is a standardized measure designed to detect change in a client’s self-perception of occupational performance over time. It can be used with persons with a wide variety of disabilities and across all developmental stages.
Summarize results
Children’s Assessment of Participation and Enjoyment and Preferences for Activities for Children (CAPE) (PAC)
(Gillian King, Mary Law, Susanne King, Patricia Hurley, Peter Rosenbaum, Steven Hanna, Marilyn Kertoy and Nancy Young, 2005)
The CAPE and PAC may be used independently or together for clients between the ages of 6and 21 years. The CAPE explores an individual’s day-to-day participation for the purpose of intervention planning or measuring outcomes. The PAC assesses an individual’s preference for activities. Activity types addressed in both measures include: recreational, physical, social, skill-based, and self-improvement.
Summarize results
Children’s Handwriting Evaluation Scale-CHES
(by Texas Scottish Rite Hospital for Crippled Children)
The evaluation tool enables a quick appraisal of deficient areas in cursive handwriting for 3rd through 8th grades. Rate and quality are evaluated based on unrehearsed copying of a short story. Quality is judged according to five criteria: letter form, slant, rhythm, spacing and general appearance.
Standard Score Percentile 90 –100 % Very Good
Rate: score score 76 – 90 % Good
25 – 75 % Satisfactory
9 – 24 % Poor
8% and Below Very Poor
Sum of Points 5 Very Good
Quality: score 4 Good
3 Satisfactory
2 Poor
0-1 Very Poor
Children’s Handwriting Evaluation Scale for Manuscript (CHES-M)
(by Texas Scottish Rite Hospital for Crippled Children)
The CHES-M is an evaluation tool that enables a quick appraisal of deficient areas in manuscript handwriting for 1st and 2nd graders. The test gives a percentile score for rate and quality based on unrehearsed copying of a short story.
Standard Score Percentile Level of Function
Rate: score score > 85 % Good
15 – 85 % Satisfactory
< 15 % Poor
Raw Score Standard Score Percentile Classification
Quality score score score 80 – 100 Good
50 – 70 Satisfactory
10 – 40 Poor
Clinical Evaluation
Summarize results
Clinical Observations of Motor and Postural Skills (COMPS)
(by Brenda N. Wilson, M.S., OT(C), Nancy Pollock, M. Sc., OT(C), Bonnie J. Kaplan, Ph.D., & Mary Law, Ph.D., OT(C))The Clinical Observations of Motor and Postural Skills (COMPS) is a screening tool for the identification of motor problems in 5- to 9- year old children.
Weighted Score
Slow Motion score
Rapid Forearm Rotation score
Finger-Nose Touching score
Prone Extension score
ATNR score
Supine Flexion score
Total: score
Minus Adjustment: score
Weighted Total Score: score
Comprehensive Test of Visual Functioning (CTVF)
(by Sue L. Larson, Evelyn Buethe, & Gary J. Vitali)
The Comprehensive Test of Visual Functioning (CTVF) evaluates visual-perceptual functioning. It is designed to give general information about overall visual perceptual processing essential for educational and clinical programming.
Total Visual Functioning Standard Score: score
Summarize results
Denver Handwriting Analysis (DHA)
(by Peggy L. Anderson, Ph.D.)
The Denver Handwriting Analysis (DHA) is an informal, criterion-referenced cursive handwriting scale designed for use with students in grades three through eight. The scale consists of subtest; near-point copying, writing the alphabet, far-point copying, manuscript-cursive transition and dictation:
Total: Parts I – III Part IV: Manuscript Cursive Transition Part V: Dictation
score % Mastery Level score % Mastery Level score & Mastery Level
Developmental Test of Visual Perception – Second Edition (DTVP-2)
(By Donald D. Hammill, Nils A. Pearson, and Judith K. Voress)
The DTVP-2 is a battery of subtests that measure different but interrelated visual perceptual and visual motor abilities. The battery was designed for use with children ages 4 through 10. The subtests include eye-hand coordination, position in space, copying, figure ground, spatial relations, visual closure, visual-motor speed and form constancy.
Quotients Percentiles
General Visual Perception score score %
Motor-Reduced Visual Perception score score %
Visual-Motor Integration score score %
Draw A Person (DAP)
(by Jack A. Naglieri)
The Draw A Person (DAP) was designed to provide a nonverbal, nonthreatening means of evaluating developmental status. It can be used with any age or disability.
Drawing / Standard Score / Percentile / Standard Scores / PercentilesMan / score / score % / (± score) score to score / score to score %
Woman / score / score % / (± score) score to score / score to score %
Self / score / score % / (± score) score to score / score to score %
Total / score / score % / (± score) score to score / score to score %
score % Confidence Interval
Total Test Classification: score
Dressing Screening
The Dressing Screener identifies developmental levels specifically in the area of dressing.
Summarize results
Erhardt Developmental Prehension Assessment –Revised (EDPA)
(by Rhoda P. Erhardt, M.S., OTR, FAOTA)
The Erhardt Developmental Prehension Assessment Revised (EDPA) measures components of arm and hand development in children of all ages and cognitive levels with developmental delays, cerebral palsy, and multiple disabilities.
Developmental Levels / Left Hand / Right HandSection 1. Primary Involuntary Arm-Hand Patterns / score / months / score / months
Section 2. Primarily Voluntary Movements / score / months / score / months
Section 3. Pre-Writing Skills / score / years / score / years
Erhardt Developmental Vision Assessment (EDVA)
(by Rhoda P. Erhardt, M.S., OTR, FAOTA)
The Erhardt Developmental Vision Assessment (EDVA) was designed to measure the motor components of visual development in children of all ages and cognitive levels with developmental delays, cerebral palsy, and multiple disabilities.
Periodic Blink: / score / per minuteSection 1. Primarily Involuntary Visual Patterns (Reflexive) / score / months
Section 2. Primarily Voluntary Eye Movements (Cognitively-directed) / score / months
Evaluation Tool of Children’s Handwriting (ETCH)
(by Susan J. Amundson, MS, OTR/L)
The Evaluation Tool of Children’s Handwriting (ETCH) looks at many tasks which occur in the classroom setting, including writing the alphabet in upper and lower cases from memory, writing numerals, copying from both a nearby model and a distant model, writing from dictation and composing a sentence. The ETCH has both a manuscript and cursive component.
Manuscript / CursiveWords / score / Words / score
Letters / score / Letters / score
Numerals / score / Numerals / score
Handwriting without Tears-Cursive
(by Jan Olsen, OTR)
Handwriting without Tears-Cursive is an evaluation tool that identifies cursive abilities and areas of concern. It addresses components such as posture, pencil grip, letter formation, and letter connections. It targets school-age children with a variety of disabilities and developmental stages.
Summarize results
Handwriting without Tears-Printing
(by Jan Olsen, OTR)
Handwriting without Tears-Printing is an evaluation tool that identifies manuscript abilities and areas of concern. It addresses components such as posture, pencil grip, spacing, size, and position in space. It targets school-age children with a variety of disabilities and developmental stages.
Summarize results
The Kohlman Evaluation of Living Skills (KELS)
(by Linda Kohlman Thomson)
The Kohlman Evaluation of Living Skills (KELS) is evaluation designed to determine a person’s ability to perform basic living skills. The following five areas are tested: Self-Care, Safety and Health, Money Management, Transportation and Telephone, and Work and Leisure).
Summarize results
Motivation Assessment Scale (MAS)
(by V. Mark Durand, Ph.D. & Daniel B. Crimmins, Ph.D.)
The Motivation Assessment Scale (MAS) was developed to help explain why inappropriate behaviors may be occurring. It weighs the influence of social attention, tangibles, escape, and sensory consequences on problem behavior.
Summarize results
Motor-Free Visual Perception Test-3 (MVPT-3)
(by Ronald P. Colarusso, EdD, Donald D. Hammill, EdD)
The Motor-Free Visual Perception Test (MVPT-3) is a test of visual perception, which avoids any motor involvement. The MVPT-3 is standardized on normal children aged four years through eleven years.
Standard Score: / scoreObservation of Hand Skills of the “K-1” Child
(by Mary Benbow MS, OTR)
Observation of Hand Skills of the “K-1” Child is a checklist of components necessary for successful handwriting.
Summarize results
Observation of Handwriting Skills
(compiled by Amanda Letsos, OTR)
This tool was compiled to look at the functional handwriting performance of the student in the classroom, identify specific areas which could impact handwriting or academic performance and provide information for future comparison.
Summarize results
Observation of Written Communication Skills
(compiled by Amanda Letsos, OTR)
This tool allows the evaluator to review rate of production with handwriting and keyboarding skills. A sixty second sample is obtained and then calculated to determine the gross words per minute (GWPM) for each of the areas. In addition, spelling skills are observed as well as the efficiency of writing.
Handwriting / KeyboardingAlphabet / score GWPM / score GWPM
Sentence Copy / score GWPM / score GWPM
Dictated Sentence / score GWPM / score GWPM
Composed Sentence / score GWPM / score GWPM
Recorded Sentence / score GWPM / score GWPM
Written Language Traits- Summarize results
Spelling- Summarize results
Occupational Therapy Psychosocial Assessment of Learning (OT PAL)
(by Sally Townsend, Paula D. Carey, Nancy L Hollins, Christine Helfrich, Melinda Blondis, Amanda Hoffman, Lara Collins, Julie Knudson, and Angela Blackwell)