OCCUPATIONAL THERAPY REFERRAL FORM

Transcription

1 OCCUPATIONAL THERAPY REFERRAL FORM MURRAY SCHOOL DISTRICT **OCCUPATIONAL THERAPY IS A HEALTH CARE PROFESSION FOCUSED ON HELPING INDIVIDUALS OF ALL AGES LEARN (OR RE LEARN) TO PARTICIPATE IN ACTIVITIES THAT OCCUPY THEIR TIME DURING THE DAY DESPITE PHYSICAL, COGNITIVE, OR SOCIAL LIMITATIONS. **SCHOOL BASED THERAPY SERVICES ADDRESS THE STUDENT S EDUCATIONAL NEEDS AND FUNCTIONAL SKILLS NECESSARY TO PARTICIPATE IN THE EDUCATIONAL ENVIRONMENT. CONSIDERATIONS PRIOR TO MAKING A REFERRAL AND INDICATIONS FOR DISCHARGE: THERE IS A DIFFERENCE BETWEEN ELIGIBILITY FOR SCHOOL BASED OCCUPATIONAL THERAPY AND THE NEED FOR CLINICAL/MEDICAL THERAPY. STUDENTS MAY RECEIVE OCCUPATIONAL THERAPY THROUGH THE SCHOOL SYSTEM ONLY IF THE CONDITION ADVERSELY AFFECTS EDUCATIONAL PERFORMANCE. SERVICES ARE BASED UPON THE EDUCATIONAL NEEDS OF THE STUDENT. PLEASE REFER STUDENTS TO OCCUPATIONAL THERAPY SERVICES IF: * THE STUDENTS DISABILITIES INTERFERES WITH THEIR ABILITY TO FUNCTION ADEQUATELY WITHIN THEIR EDUCATIONAL SETTING AND IS SIGNIFICANTLY LOWER THAN THAT OF PEERS * CURRENT LEVEL OF ACHIEVEMENT IS NOT CONSISTENT WITH OTHER AREAS OF DEVELOPMENT *THE STUDENTS SKILL LEVEL IS LESS THEN WOULD BE EXPECTED GIVEN THE STUDENTS COGNITIVE SKILLS, MATURITY LEVEL AND EXPOSURE TO ACTIVITIES * FUNCTIONAL LIVING SKILLS ARE A PART OF THE STUDENT S SPECIAL EDUCATIONAL PROGRAM * STUDENT DOES NOT HAVE APPROPRIATE STRATEGIES TO COMPENSATE FOR THEIR DEFICITS * ASSISTIVE TECHNOLOGY IS NEITHER AVAILABLE OR EFFECTIVE * MODIFICATIONS TO TESTING PROCEDURES OR WRITTEN COMMUNICATION FORMATS ARE NOT EFFECTIVE * MODIFICATIONS TO THE SCHOOL AND/OR WORK ENVIRONMENT HAVE BEEN MADE AND ARE NOT EFFECTIVE * NEEDED STRATEGIES CANNOT BE IMPLEMENTED EFFECTIVELY BY CURRENT EDUCATIONAL TEAM SERVICES MAY BE DISCONTINUED AT ANY TIME AND BEGIN AGAIN WITH A NEW REFERRAL AS THE STUDENTS EDUCATIONAL NEEDS CHANGE. INDICATIONS FOR DISCHARGE MAY INCLUDE: *SCHOOL BASED STAFF IS AWARE OF AND UNDERSTANDS IMPLICATION OF THE STUDENT S MEDICAL AND/OR PHYSICAL CONDITION AND IS MANAGING THE STUDENT S ENVIRONMENT APPROPRIATELY. *THERAPY IS NO LONGER AFFECTING CHANGE IN THE STUDENT S LEVEL OF FUNCTION OR RATE OF SKILL ACQUISITION *STUDENT IS DEMONSTRATING PROGRESS TOWARD IEP GOALS AND OBJECTIVES/BENCHMARKS WITHOUT SUPPORT OF RELATED SERVICES. TO MAKE A REFERRAL TO OCCUPATIONAL THERAPY: YOU MUST ATTEMPT AND DOCUMENT, ON PROVIDED DATA SHEET, TWO INTERVENTION STRATEGIES IN EACH AREA OF CONCERN. AFTER APPLYING A VARIETY OF STRATEGIES SHOULD THE CHILD CONTINUE TO STRUGGLE OR FALL BEHIND PEERS, COMPLETE REFERRAL FORM AND SUBMIT IT WITH THE PRE REFERRAL INTERVENTION DATA SHEET, APPROPRIATE CLASSROOM WORK, AND PERMISSION TO TEST TO: CATHERINE BIGELOW LIBERTY ELEMENTARY SCHOOL.

2 PRE-REFERRAL INTERVENTION STRATEGIES PROBLEM WITH HANDWRITING PENCIL GRIP LETTERS NOT RIGHT SIZE NOT WRITING ON THE LINE DIFFICULTY WITH SPACING DIFFICULTY WITH COPYING : NEAR POINT AND FAR POINT PENCIL PRESSURE INTERVENTION STRATEGIES *ISOLATED FINGER EXERCISES *PICK UP SMALL ITEMS WITH CLOTHESPINS, TONGS, TWEEZERS *PLAY WITH SPINNING TOPS, PICK UP STICKS, WIND UP TOYS, PEGBOARD ACTIVITIES, LITE BRITE ETC. * PICK SMALL OBJECTS SUCH AS PEGS, BUTTONS, OR BEADS OUT OF PLAYDOUGH OR PUTTY *ROLL SMALL PIECES OF PUTTY OR CLAY BETWEEN THE PADS OF THE THUMB AND INDEX FINGER TO MAKE SMALL BALLS. * COLOR OR WRITE WITH SHORT CRAYONS OR CHALK * USE A TRIANGULAR PENCIL OR PENCIL GRIP *USE PAPER WITH A DOTTED MIDLINE * HAVE THE STUDENT FIT LETTERS INTO SQUARES OF GRAPH PAPER * DRAW APPROPRIATE SIZED BOXES ON LINED PAPER FOR LETTERS TO FIT INTO *PROVIDE STUDENT WITH LETTER STRIP OR NUMBER LINE FOR REFERENCE OF WHERE LETTERS FIT WITHIN THE LINES *USE VISUAL CUES FOR EXAMPLE COLORED LINES (BLUE IS THE SKY, GREEN IS THE GRASS, BROWN IS THE GROUND OR HIGHLIGHT BOTTOM LINE) *USE WOOD OR CLEAR GLUE TO MAKE A SENSORY GUIDE LINE AT THE BOTTOM *ALLOW THE CHILD TO USE A FINGER, PENCIL, POPSICLE STICK, FOR SPACING * HAVE THE CHILD WRITE ON GRAPH PAPER LEAVING ONE BOX EMPTY IN BETWEEN WORDS *ALLOW STUDENT TO COPY BOARD MATERIAL FROM A PAPER ON THE DESK *REDUCE AMOUNT OF BOARD WORK AND TEXTBOOK COPYING * PROVIDE A MODEL WHEN APPROPRIATE * PROVIDE VISUALS OF IMPORTANT CONCEPTS TOO MUCH * WRITE WITH A MECHANICAL PENCIL *HAVE THE STUDENT WRITE ON CORRUGATED CARDBOARD WITHOUT FLATTENING THE BUMPS. *WRITE ON ALUMINUM FOIL BACKED WITH CARDBOARD TRY NOT TO RIP THE FOIL WHEN THEY WRITE TOO LITTLE *HAVE THE STUDENT USE TRACING PAPER OR CARBON PAPER *RUB WAX OVER A SQUARE OF PAPER THEN TURN IT OVER ONTO ANOTHER PIECE OF PAPER. HAVE THE STUDENT PRESS HARD ONTO THE PAPER AND DRAW SHAPES SO THE WAX LEAVES MARKS.

3 WRITING LOOKS JERKY *WRITING HAND SHOULD REST ON THE TABLE WITH LITTLE MOVEMENT IN THE HAND AND ARM. FINGERS SHOULD DO MOST OF THE WORK. * HAVE STUDENT COMPLETE ACTIVITIES SUCH AS: DOT TO DOTS, MAZES, TRACE DOTTED DESIGNS *HAVE THE STUDENT FORM STRAIGHT LINES DOWN, CONTINUOUS LOOPS, ZIG ZAGS, BUMPS UP (LIKE A CONTINUOUS LETTER /M/) BUMPS DOWN * MAKE A DESIGN GOING ROUND AND ROUND KEEPING WRIST ON THE TABLE AND MOVING ONLY FINGERS. *DECREASE THE AMOUNT OF REQUIRED WRITTEN WORK * ALLOW MORE TIME TO COMPLETE WORK *ALLOW STUDENT TO USE WORD PROCESSOR FOR WRITING ASSIGNMENTS *EXPECT STUDENT TO MEET REASONABLE CRITERIA FOR NEATNESS PROVIDE VISUALS OF IMPORTANT CONCEPTS *** MAKE SURE STUDENT IS POSITIONED PROPERLY PRIOR TO WRITING. PROBLEM WITH CUTTING *UNABLE TO OPEN AND CLOSE SCISSORS *UNABLE TO HOLD SCISSORS * UNABLE TO ROTATE PAPER INTERVENTION STRATEGIES *TRY SELF OPENING/SPRING SCISSORS THAT AUTOMATICALLY OPEN WHEN PRESSURE IS RELEASED * PRACTICE GRASP AND RELEASE PATTERNS USING KITCHEN TONGS, SPRAY BOTTLES OR TWEEZERS. *TRY LOOP SCISSORS THAT DO NOT HAVE FINGER HOLES *START WITH SMALL PIECES OF CARDSTOCK * PUNCH A HOLE OR CLUSTER OF HOLES IN THE PAPER. HAVE THE STUDENT CUT FROM ONE HOLE TO THE NEXT. * START WITH WIDE STRAIGHT LINES AND PROGRESS TO SQUARES, CIRCLES AND MORE COMPLEX SHAPES. * A RIGHT HANDED CUTTER SHOULD CUT IN A COUNTER CLOCKWISE FASHION, WHILE A LEFT HANDED CUTTER SHOULD CUT IN CLOCKWISE FASHION, THIS ALLOWS THE CHILD TO SEE THE SHAPES OR PICTURE THEY ARE CUTTING OUT.

4 PROBLEM WITH DRESSING TAKING CLOTHES ON/OFF DIFFICULTY WITH FASTENERS (I.E. BUTTONS, ZIPPERS) INTERVENTION STRATEGIES *BACKWARD CHAINING: COMPLETING THE ENTIRE PROCESS, BUT LEAVING THE LAST PART FOR THE STUDENT TO DO. AS THE LAST SKILLS IS MASTERED INTRODUCE THE SECOND TO LAST STEP, THEN THE THIRD TO LAST, AND SO ON. *START WITH BIG BUTTONS AND BUTTON HOLES. *PRACTICE THE SKILL WITH THE CLOTHING PLACED ON THE TABLE FIRST. *GIVE THE CHILD VERBAL CUES TO HELP TALK THEM THROUGH THE STEPS. *BACKWARD CHAINING * ISOLATED FINGER EXERCISES PROBLEM WITH ATTENTION INTERVENTION STRATEGIES DIFFICULT TO ATTEND *REDUCE DISTRACTIONS *VISUAL DISTRACTIONS AT THE DESK, ON THE BOARD AND IN THE CLASSROOM *NOISE IN THE CLASSROOM AND OUT IN THE HALL *LOCATION IN THE CLASSROOM. *GIVE SHORT CLEAR INSTRUCTIONS AND HAVE THE STUDENT REPEAT BACK THE INSTRUCTIONS. * ALLOW REGULAR BREAKS * PROVIDE A SEPARATE WORK STATION WITH LIMITED DISTRACTIONS *CREATE A CUBICLE FOR THE STUDENT DURING INDEPENDENT WORK TIME. CUBICLE CAM BE MADE OUT OF 2 FILE FOLDERS TAPED TOGETHER OR EMPTY BINDERS DIFFICULT TO ATTEND DUE TO SENSORY NEEDS *LIMIT THE AMOUNT OF VISUAL MATERIAL ON THE WALLS OR CEILING. * ORGANIZE THE CLASSROOM TO HAVE SPECIFIC PLACE FOR BOOKS, ACTIVITIES AND OTHER ITEMS. *PROVIDE A PREDICTABLE SCHEDULE. REVIEW THE SCHEDULE AND EXPECTATIONS EACH DAY. * PROVIDE A QUIET CORNER IN THE CLASSROOM WHEN THE STUDENT CAN READ OR LISTEN TO MUSIC IF THEY ARE FEELING OVERWHELMED. * HAVE THE CHILD PERFORM HEAVY WORK ACTIVITIES SUCH AS WALL PUSH UPS, CHAIR PUSH UPS, CARRY HEAVY BOOKS. *ALLOW THE CLASS FREQUENT MOVEMENT BREAKS THAT ARE SHORT AND INCLUDE STRETCHING AND DEEP BREATHING.

5 PRE-REFERRAL INTERVENTION DATA AREA OF DIFFICULTY: DATE: ATTEMPTED STRATEGY OBSERVATIONS: WHAT WORKED AND WHAT DIDN T WORK? FOR HOW LONG AREA OF DIFFICULTY: DATE: ATTEMPTED STRATEGY OBSERVATIONS: WHAT WORKED AND WHAT DIDN T WORK? FOR HOW LONG AREA OF DIFFICULTY: DATE: ATTEMPTED STRATEGY OBSERVATIONS: WHAT WORKED AND WHAT DIDN T WORK? FOR HOW LONG

6 OCCUPATIONAL THERAPY REFERRAL FORM STUDENT: SCHOOL: DATE OF REFERRAL: CLASSIFICATION: DOB: GRADE: SPED TEACHER: TEACHER: MEDICAL DIAGNOSIS: STUDENT HAS NO KNOWN DIAGNOSIS: MEDICATIONS: OTHER MEDICAL CONCERNS: CURRENT SERVICES: CURRENT IEP 504 SPEECH PHYSICAL THERAPY OTHER SCHOOL RELATED OR OUTSIDE SERVICES: PARENTAL CONSENT TO EVALUATE: YES NO DATE OF PARENT SIGNATURE: PARENT(S): PHONE/ IQ TESTING: NAME OF TEST: FULL SCORE: PERFORMANCE: DATE GIVEN: VERBAL: ACADEMIC LEVELS: READING: SPELLING: MATH: REFERRED BY:

7 AREAS OF CONCERN: SCHOOL FINE MOTOR SKILLS PRE WRITING SKILLS WRITTEN COMMUNICATION (PLEASE PROVIDE A COPY OF CLASSROOM WORK) HANDWRITING : RATE/LEGIBILITY/REVERSALS/LETTER SIZE/ ALIGNMENT/SPACING TOOL USE HOLDING/MANIPULATING SCISSORS GRASP/HOLDING PENCIL AND/OR CRAYONS USING A KEYBOARD PRE ACADEMIC/ACADEMIC (PLEASE PROVIDE A COPY OF CLASSROOM WORK) COPYING WRITTEN WORK FROM THE BOARD/DESKTOP DISCRIMINATING SHAPES, COLORS, NUMBERS, LETTERS SELF MANAGEMENT (SENSORY PROCESSING) COPING WITH NEW OR DIFFERENT SITUATIONS/TRANSITIONS STAYING IN SEAT OVER/UNDER RESPONSIVE DEMONSTRATING SELF CONTROL

8 SELF MANAGEMENT (CONTINUED) ORGANIZING SELF/MATERIALS SUSTAINING ATTENTION SPAN SELF CARE/ACTIVITIES OF DAILY LIVING FEEDING/CAFETERIA TOLERATING A VARIETY OF FOODS/TEXTURES EXCESSIVE SPILLAGE/MESSY EATER CARRYING TRAY THROUGH LINE TO TABLE USING UTENSILS SITTING AT LUNCHROOM TABLE DRESSING FOR TOILETING OR OUTDOOR CLOTHING PUTTING ON/TAKING OFF COAT TYING SHOES MANAGING FASTENERS ON CLOTHING SCHOOL HYGIENE (WASHING)

9 ENVIRONMENTAL ACCESS: BATHROOM (FAUCETS & TOWELS) / DRINKING FOUNTAINS/ BACKPACKS/ LOCKERS/ LUNCHROOM /COMPUTERS ENDURANCE AND FATIGUE MOTOR PLANNING: CATCHING/THROWING/KICKING A BALL RUNNING/SKIPPING/HOPPING/JUMPING SUMMARY OF REFERRAL: