OCCUPATIONAL THERAPY NOTES Diagnosis: ___________________ Date of Birth: _________________

Child’s Name: ________________ Date of Service: _______________

Diagnosis: ___________________ Date of Birth: _________________ ___ Individual Treatment ___ Group
___ Telehealth ___ Consultation

___ Individual Treatment ___ Group Treatment Provided:

___ Telehealth ___ Consultation Fine Motor Handwriting Functional Skills
Visual Motor Visual Perceptual Adaptive Equip.
Treatment Provided: Gross Motor Motor Planning Therapeutic Handling
Fine Motor Handwriting Functional Skills Range of Motion Positioning Feeding
Visual Motor Visual Perceptual Adaptive Equip. ADL Strengthening Sensory Integration
Gross Motor Motor Planning Therapeutic Handling
Range of Motion Positioning Feeding Assessment:
ADL Strengthening Sensory Integration

Assessment:

Plan:

Plan: Signature of
Date
Signature of Supervising OT
Supervising OT

Signature of
OTA
Signature of Date OCCUPATIONAL
OTA THERAPY NOTES
Child’s Name: ________________ Date of Service: _______________

Milestones Child Developmental Center Milestones Child Developmental Center