OCCUPATIONAL THERAPY NOTES OCCUPATIONAL THERAPY NOTES

Child’s Name: ________________ Date of Service: _______________ Child’s Name: ________________ Date of Service: _______________
Diagnosis: ___________________ Date of Birth: _________________ Diagnosis: ___________________ Date of Birth: _________________

___ Individual Treatment ___ Group ___ Individual Treatment ___ Group
___ Telehealth ___ Consultation ___ Telehealth ___ Consultation

Treatment Provided: Treatment Provided:

Fine Motor Handwriting Functional Skills Fine Motor Handwriting Functional Skills
Visual Motor Visual Perceptual Adaptive Equip. Visual Motor Visual Perceptual Adaptive Equip.
Gross Motor Motor Planning Therapeutic Handling Gross Motor Motor Planning Therapeutic Handling
Range of Motion Positioning Feeding Range of Motion Positioning Feeding
ADL Strengthening Sensory Integration ADL Strengthening Sensory Integration

Assessment: Assessment:

Plan: Plan:

Signature of Date Signature of Signature of Date Signature of

OTA Supervising
supervising OT OTA Supervising OT