Occupational Therapy Evaluation

Client’s Name: Gretchin

Address: Columbus, Ohio
Phone: 614-247-5024
Date of Birth: August 21, 1999
Date of Report: December 29, 2015
Chronological Age: 16 years
Billing Source: Insurance

Medical Diagnosis: Attention Deficit Disorder

Reason for Referral: Evaluation and treatment of attention, task organization, and socialization within school setting
Time Spent: 23 minutes
Recommendation Summary: Gretchin will be seen by occupational therapy 2x/week for 60 minutes to address client-stated goals of
improving her relationship with her family and her boyfriend, decreasing her drug use, and increasing her concentration on school work.

Case History: Gretchin is a 16-year-old female. She has a diagnosis of ADD. She also has a history of depression. She is in the 10th
grade at Columbus High School and has a history of struggling with attention, task organization, and social relationships in the school
setting.

Vision/Hearing: No reports of vision or hearing problems.

Assessments Administered: Properly credentialed personnel provided material and test administration in the primary language of
the student. The tests and assessment materials utilized are considered to be not racially, culturally, or sexually biased, and were used
in the manner for which validated, except as noted.

Tests Administered: The Canadian Occupational Performance Measure (COPM) was administered at this time (results below).
Information in the evaluation was also obtained by history provided by client’s mother/father, client, chart review, clinical interview, and
clinical observations.

Behavior: Gretchin was pleasant and talkative during the administration of the assessment. She was fidgety (rocking in her chair,
playing with her hair), looking around the room, and was sometimes unable to pay attention to questions asked which resulted in
questions being repeated. She reported that she is always getting in trouble in school and has been kicked out of school multiple times
due to disruptive behavior.

Activities of Daily Living: Gretchin stated she sometimes doesn’t shower because she forgets. She stated her mind feels like it’s
everywhere and she also doesn’t always want to be at home because her mom is abusive (yells, hits). She reported she doesn’t eat
every meal d/t lack of appetite.

Instrumental Activities of Daily Living: Gretchin reported she has no issues with community mobility. She takes the bus to school
which she has no difficulties with. She relies on her boyfriend, Rob, for all other transportation which she stated is frustrating at times
because he’s not always reliable (late or doesn’t show up). Gretchin is not working or volunteering and she doesn’t wish to do so
despite her mom telling her she should work. She stated her house is very messy because her dad left and took her sister. Now her
mom doesn’t do anything to keep the house clean, so she refuses to as well. Gretchin reported she is using drugs (ecstasy, cocaine,
acid) which interferes with many of her occupations, but she has no other hobbies and it helps numb her feelings.

Social Skills: Gretchin stated she has a great relationship with her friends and she relies on them for most of her support. She is in a
relationship with a boy named Rob. She stated their relationship is good, but he relies on her for emotional support because he is a
cancer survivor and lost his mother to cancer. This makes her feel pressured to always be there for him. She also reported when they
are using drugs, they argue frequently. She stated her mom is abusive, so their relationship is poor. Her dad and sister left, so she does
not have a relationship with them either. She also reported she used to play soccer but quit because she couldn’t focus on the game
and was embarrassed.

Strengths: Supportive of boyfriend, healthy relationships with friends, feels supported by friends

Areas of Improvement: Abusive relationship with mother, non-existent relationship with father and sister, substance abuse in
social situations

Fine Motor Skills: Per client and parent report, Gretchin’s skills in these areas are currently within age appropriate limits.

Strength, Upper Extremity Coordination, & Balance: Per client and parent report, Gretchin’s skills in these areas are currently
within age appropriate limits.

Cognition (problem solving, attention, organization, thought process): During assessment administration, Gretchin had
difficulties with attention (rocking in chair, playing with hair, looking at pictures on walls, inability to focus on questions being asked).
She reported having life-long problems in school due to her difficulty with attention and concentration.

Outcome Measures:
Canadian Occupational Performance Measure:
The COPM is an outcome measure that is used to detect change in a client’s perception of occupational performance over time. The
specific focus of the COPM on client–identified problems is intended to facilitate collaborative goal setting, between the therapist and
client.

Administration: Via semi-structured interview, the client is asked to identify any activities that are difficult to perform across the areas of
self-care, work and leisure. The client is then asked to identify the five most important problems on a scale of 1 (not important at all) to
10 (extremely important), then rate his or her performance and level of satisfaction in these activities.

Scoring and Interpretation: The client scores each of the five identified problem areas (both at assessment and re- evaluation) on a
scale of 1 to 10 for both performance (1 = not able to perform task to 10 able to complete task well) and satisfaction (1 = not satisfied to
10 extremely satisfied). The performance and satisfaction scores of the selected activities are summed and averaged over the number
of problems, to produce scores out of 10. A difference between the initial and subsequent score (change score) of two or more is
considered clinically significant.

INITIAL ASSESSMENT
Occupational Performance Problems:
Performance 1 Satisfaction 1
1. Socializing with family 2 1
2. Improving relationship with boyfriend, Rob 6 7
3. Stop substance abuse 3 2
4. Concentrating on schoolwork 2 2
Scoring: Performance Satisfaction
Score 1 Score 1
Total Score= Total performance or satisfaction scores 13/4 = 3.25 12/4 = 3
# of problems

Goals:
1. Gretchin and her mother will cook dinner together 2 nights/wk to improve communication skills and problem-solving skills as a family.
2. Gretchin will identify 3 leisure activities of interest and complete a desired leisure activity 3x/wk to maintain a drug-free life.
3. Gretchin will identify level of arousal and implement sensory strategies 3x/school day to increase concentration.

Summary & Recommendations for Treatment:

Overall, Gretchin shows strengths in social skills, community mobility, and motor skills. After completing the COPM, Gretchin identified
her areas for improvement as socializing with family, her relationship with her boyfriend, substance abuse, and concentration on
schoolwork. It is recommended that Gretchin be seen by occupation therapy to address building a relationship with her family,
improving her relationship with her boyfriend, decreasing her substance use, and increasing her concentration on schoolwork. Her
progress will be re-evaluated at 3 and 6 months and appropriateness of OT services assessed. Assessment of progress will be ongoing
and goals will be updated accordingly. Progress reports will be generated every 8 weeks.

Thank you for your time. It was a pleasure meeting Gretchin.

Thank you,
Occupational Therapist, OTR\L
Occupational Therapist