Occupational Therapy School-based Intervention Plan

This document is confidential per the standards of the Greene County Educational Services Center

Student Name: IEP Date:

DOB: if applicable: Medicaid id# ETR Date:
Sp Ed Disability/ Dx: Grade:
Teacher/Interv.Specialist: OT Minutes/ mo:
Allergies/ Precautions: Hand Dominance: R L
Accommodations/ Equipment: Grasp:

Goals/ Objectives:

□ Therapeutic procedure/ Therapeutic Activities

□ Neuromuscular re-education

□ Sensory integrative techniques

ATTENDANCE CODES: A=Absent N=No School SD=One/Two Hr Delay SP=Special Event TM=Therapist@Mtg TA=Therapist Absent

TIME CODE: D=Direct I= Indirect C= Consult

JULY 20___ AUG 20___ SEP. 20___ OCT 20___ NOV. 20___ DEC. 20___
Date/ Time Date/ Time Date/ Time Date/ Time Date/ Time Date/ Time

Thanksgiving Winter Break

Winter Break
JAN. 20___ FEB. 20___ MAR 20___ APR 20___ MAY 20___ JUNE 20___
 Date/ Time Date/ Time Date/ Time Date/ Time Date/ Time Date/ Time

Page One of Two OT POC This document is confidential per the standards of the Greene County Educational Services
Center

Page Two of Two OT POC

Student Name_______________________________

Occupational Therapy Interventions to modify, restore and/ or develop skills:

Activities of Daily Living:
___Dressing/ Fasteners
___Feeding
___Hygiene
Sensory Interventions:
___ Transfers ___Sensory Inputs/ Modifications:[ circle those that apply]
positioning at front or end of line, desk placement in classroom,
___ Organization of Supplies
Other [edit]_______________
___ Locker/ Desk Mgmt

___Grooming ___ Book bag Management

___ Proprioceptive:
___ Durable Medical Equipment
weighted vest, ankle weights, weighted hat, weighted
Acquisition/Fitting/ Safety/ Staff Training lap pillow, pressure vest, heavy work, deep pressure,
oral-motor inputs, resistive bands around chair/ desk
___ Adaptive Equipment
legs bean bag chair, tall kneel or standing options for
Acquisition/Fitting/ Safety/ Staff Training writing,

___Other [edit]________________________ Other [edit]_______________

Motor Interventions:
__Vestibular
___Reflex Integration ___Hand Skills: (stable web
movement breaks, heavy work, sit-n-move cushion,
___Motor Planning separation of hand vibrating writing tool, Other [edit]_______________
___Proximal Stability/Distal Function in-hand rotation
___Tactile
squirrel, de-squirrel
brushing program, transition item, vibrating writing tool
___Crossing Midline palmar translation)
Other [edit]_______________
___Bilateral Coordination ___Tool Grasp/ Use
___Gustatory/ Olfactory, mint/cinnamon hard
___One-handed Techniques (writing tool, tongs candy, feeding stimuli, Other [edit]__________
___Hand/ Finger Strengthening utensils, scissors,
___Auditory
 ___Other [edit]________________________ head phones, designated quiet area
Visual-Motor Interventions: ___Other [edit]_______________
___ Midline Orientation ___Visual Perception
___Visual
___ Dominance/ Laterality (Visual Memory,
visual schedule, limit extraneous visual stimuli,
___Directionality Same Matching,
Other [edit]__________
___Eye-Hand Coordination Similar Matching,

___Compensatory Techniques Visual Discrimination

[colored writing lines, Figure-Ground,

raised writing lines] Match Differing Objects)

___Occulomotor (eye tracking, eye teaming, convergence)

___Other [edit]________________________

Outcomes / Discharge Plan- Occupational Therapy Services will be discontinued when the student is:

___ demonstrating fine motor skills necessary to be successful in the school environment.

___ performing at his/her highest level of independent function within the school environment.

___ independently utilizing self-modulation skills and/or sensory motor modifications/ support in the classroom are

sufficient that sensory issues are no longer or are minimally interfering with child’s school performance.

___Other [edit]________________________

Occupational Therapist Signature ____________________________________________________

Date_______

Occupational Therapy Assistant Signature ____________________________________________

Date_________
**************************************************************************************************************************
***********
POC Reviewed (date) __________ and the following amendments are
made:________________________________
_____________________________________________________________________________________
_________
Occupational Therapist Signature ____________________________________________________
Date_______
Occupational Therapy Assistant Signature ____________________________________________
Date_________

Addendum:
This plan of care is now transferred to Occupational Therapist of record (Name if known)_____________________________________ at new
school setting: (ie: GC Learning Center, IYS/PHP, other:_______________ Date of Student’s School Transfer:
________________________
Signature of Initial Therapist
__________________________________________Date_________________

Received (date)________________ I have reviewed and will adopt this POC as written YES NO
Signature of Receiving Therapist______________________________________
This document is confidential per the standards of the Greene County Educational Services Center