Initial OT Summary - School

Client Name: Emily Johnson Assessment date: October 15, 2023 Main reason for referral: - Emily has been referred due to difficulties in maintaining attention and completing tasks in the classroom setting. Background information: - Emily is a 7-year-old girl with a history of mild developmental delays. She has been receiving speech therapy for the past year. Current functioning: - Emily is able to follow simple instructions but struggles with multi-step tasks and often requires redirection. Self-care: - Emily can dress herself but needs assistance with buttons and zippers. She is independent in feeding but requires reminders for hygiene tasks. Motor skills: - Emily demonstrates age-appropriate gross motor skills but has difficulty with fine motor tasks such as writing and cutting with scissors. Self-management: - Emily has difficulty organizing her belongings and managing her time effectively, often leading to incomplete assignments. Classroom/learning: - Emily struggles with maintaining focus during lessons and often requires additional support to complete her work. Social/play skills: - Emily interacts well with peers but can become frustrated during group activities if she feels overwhelmed. Communication skills: - Emily communicates effectively with peers and adults but sometimes struggles to articulate her thoughts clearly. Main areas of OT focus: - The main areas of focus will be improving Emily's fine motor skills, enhancing her self-management abilities, and supporting her classroom participation. OT goals: - Improve fine motor skills to enable independent writing and cutting. - Develop strategies for better self-organization and time management. - Enhance focus and task completion in the classroom setting.