School-Based Occupational Therapy Evaluation
Please complete this questionnaire to help assess the student's occupational therapy needs within the school environment.
Student Full Name
*
First Name
Last Name
Grade Level
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Other
Teacher's Name
*
School Name
*
Reason for Referral
*
Fine motor difficulties
Sensory processing concerns
Self-care challenges
Classroom participation issues
Other
Fine Motor Skills Assessment
*
Rows
Never
Sometimes
Often
Always
Uses scissors effectively
1
2
3
4
Writes legibly
5
6
7
8
Manipulates small objects
9
10
11
12
Buttons/zips clothing
13
14
15
16
Sensory Processing
*
Rows
Not at all
Rarely
Sometimes
Frequently
Easily distracted by noises
17
18
19
20
Seeks movement (rocking, spinning)
21
22
23
24
Overreacts to touch or textures
25
26
27
28
Shows strong preferences for certain foods/textures
29
30
31
32
Self-Care Skills
*
Rows
Independent
Needs some help
Needs much help
Dependent
Dressing
33
34
35
36
Feeding
37
38
39
40
Toileting
41
42
43
44
Hand washing
45
46
47
48
Classroom Participation
*
Rows
Never
Sometimes
Often
Always
Follows directions
49
50
51
52
Stays seated
53
54
55
56
Completes tasks
57
58
59
60
Transitions between activities
61
62
63
64
Social Skills/Peer Interaction
*
1
2
3
4
5
Additional Comments or Observations
Recommendations for Occupational Therapy Support
Submit Evaluation
Should be Empty: