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Justification for Occupational Therapy Preschool Aged Student Example

Updated on April 26, 2020

Justification for Occupational Therapy Evaluation

Name: Student Name

Address: Service Provided at:

123 ABC Lane

Somewhere, NY

Telephone: 555-555-5555

Parents: Name

Date of Birth: 07/16/2015

Date of Request: 11/30/2019

County: Somewhere

Service Coordinator: Name

Evaluator(s): Teacher Name, MSEd.

Special Educator

Student Name is 4 year 4 month old boy receiving special education services 4 times a week and speech services 3 times a week through Somewhere County Committee on Preschool Special Education. He receives his special education and speech services at Daycare in Somewhere, NY. Student Name lives at home with his mother and father. Student Name’s special education therapy sessions focus on identifying, colors, shapes and quantity concepts, demonstrating age appropriate play skills, attending to teacher directed lessons and transitioning from preferred to less preferred activities. During speech therapy sessions, Student Name is working on utilizing spoken language effectively across settings and improving his intelligibility to communicate his wants and needs

It is suggested that Student Name receives an Occupational Therapy Evaluation to assist Student Name in independently performing classroom tasks (cutting, coloring and pre-writing skills), self-care tasks (buttoning pants, zippering coat and fastening shoes) and to assist Student Name in using sensory strategies to better control his body, focus his attention and display appropriate behaviors in the classroom. Student Name shows weak fine motor skills when performing classroom tasks such as coloring, ripping paper and cutting. He shows a lack of endurance and tires easily when performing these tasks. Student Name does not enjoy using art activities that involve messy mediums. He also has difficulty creating pictures independently with detail and organization. Student Name struggles with self-help skills. He has difficulty buttoning his pants on his own, zippering his coat without support, and putting on and fastening his Velcro shoes. Student Name would also benefit from sensory strategies to help with his distractibility, poor concentration, trouble paying attention, trouble staying seated, tiring easily, and his tendency to push, yell and hit.

It is the decision of Student Name’s speech and special education therapist that Student Name be referred for an Occupational Therapy evaluation to determine if his fine motor and sensory performance, are currently at an appropriate level in order for him to move through the developmental milestones.

It is a pleasure working with Student Name and his family. If you have any questions or concerns regarding this report, please feel free to contact school name at (555) 555-5555

Teacher Name, MS Ed.

Special Educator

NPI#: #####



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