Sample School Based Ot Intervention Plan of Care

SCHOOL-BASED OCCUPATIONAL THERAPY INTERVENTIONPLAN/PLAN OF CARE
Client Name: _____________________________________________ DOB: _____________________
IEP Begin/End dates: ____________________________ Frequency/Session length: _______________
COMMON CORE/ESSENTIAL STANDARDS TO BE ADDRESSED:

SUBJECT AREA STANDARD
STUDENT PARTICIPATION AREAS TO BE ADDRESSED: (check all that apply)

Personal Care (feeding, toileting, dressing, hygiene, managing personal belongings, personal organization, mobility)
Student role/Interaction Skills (following classroom/specials/school/bus/cafeteria protocols & routines, safety
awareness, respecting the space/time/materials of others, requesting help, making needs/wishes known, social awareness,
building/maintaining relationships)
Learning academics/Process skills (following demonstrations, copying models, carrying out verbal directions, attending
to instruction, completing assignments)
Functional Academics (using classroom tools, managing and using materials, building models, using objects to express
concepts, using technology)
Play (turn-taking, imaginative play, sharing materials, exploring new play ideas/opportunities)
Community Integration/Work (fieldtrips, school-related vocational training)
Graphic communication (handwriting, keyboarding, drawing, coloring, art)
STUDENT PERFORMANCE COMPONENTS TO BE ADDRESSED: (check all that apply)

Mental Functions:
cognition attention memory coping and behavioral regulation
self-esteem level of arousal sleep sequencing complex movements
motivation impulse control perception thought (recognition, categorization, generalization)
Sensory Functions and Pain:

seeing/related functions hearing functions vestibular taste pain
smell proprioceptive functions touch functions temperature and pressure
Neuromuscular and Movement Related Functions:

ROM joint stability strength ocular control endurance reflexes
eye-hand coordination bilateral integration crossing midline fine and gross motor control tone
POSSIBLE INTERVENTION ACTIVITIES:

GOALS, FREQUENCY, DURATION, LOCATION OF SERVICES – found in IEP
SKILLED INTERVENTION APPROACHES: (check all that apply)

 Create/Promote (e.g., health promotion)
 Establish/Restore (e.g., skill acquisition or remediation)
 Modify/Adapt (e.g., environmental modification)
 Prevent (e.g., early intervening support; avoiding secondary complications)
 Occupation-based interventions (training embedded in actual activity e.g., personal care, using classroom tools)
 Explicit intervention:
 Promote engagement
 Describe task/expected performance
 Break task into manageable parts
 Model task performance (showing)
 Facilitate and guide student practice (e.g., checking for understanding & providing corrective feedback)
 Facilitate and assess independent practice/trials
 Facilitate generalization of task performance across settings
 Preparatory methods:
Therapeutic exercise Treatment of oral function/oral motor techniques
Sensory activities Splinting/orthotics
Visual perceptual training Assistive technology/Adaptive equipment training
PRECAUTIONS:
SKILLED INTERVENTION TYPES: (check all that apply)

 ONE-ON-ONE INTERACTION  GROUP
 WHOLE CLASS  PROGRAM/ROUTINE DEVELOPMENT
 CONSULTATION WITH TEAM MEMBERS (e.g., problem solving)
 EDUCATION OF TEAM MEMBERS (e.g., training)
 ENVIRONMENTAL ADAPTATION (e.g., assistive technology)
PLAN FOR EXIT FROM SERVICES:

The IEP team will consider data for the student to be exited or Plan of Care will be modified in accordance with student’s
needs based on one or more of the following events:
1) Goals are achieved
2) OT is no longer required for the student to benefit from special education program at this time
3) Parent request
TEAM DISCUSSION ON SUGGESTIONS FOR PARENT and TEACHERS:
COMMUNITY SUPPORTS & COLLABORATION (e.g. community programs/resources, other disciplines):
This plan was created by: _________________________________ (Therapist Signature and Credentials)
on: __________________ (date)

Sample School Based Ot Intervention Plan of Care

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SCHOOL-BASED OCCUPATIONAL THERAPY INTERVENTIONPLAN/PLAN OF CARE

Client Name: _________________________ DOB: _

IEP Begin/End dates: ______________ Frequency/Session length: _

COMMON CORE/ESSENTIAL STANDARDS TO BE ADDRESSED:

STUDENT PARTICIPATION AREAS TO BE ADDRESSED: (check all that apply)

STUDENT PERFORMANCE COMPONENTS TO BE ADDRESSED: (check all that apply)

Sensory Functions and Pain:

Neuromuscular and Movement Related Functions:

POSSIBLE INTERVENTION ACTIVITIES:

SKILLED INTERVENTION APPROACHES: (check all that apply)

SKILLED INTERVENTION TYPES: (check all that apply)

PLAN FOR EXIT FROM SERVICES:

TEAM DISCUSSION ON SUGGESTIONS FOR PARENT and TEACHERS:

COMMUNITY SUPPORTS & COLLABORATION (e.g. community programs/resources, other disciplines):

on: __________________ (date)

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