CONFIDENTIAL REPORT

OCCUPATIONAL THERAPY EVALUATION

General Information
Name Gemma Bettencourt Date of Evaluation August 19, 2018
Date of birth 1.18.2008 Chronological Age 10
School Lake Ridge Academy Grade 4
Evaluator Jason Gonzales OTRL Gender Female

Purpose of Evaluation
The purpose of an Occupational Therapy assessment within the school setting is to determine whether
OT services are necessary for the student to participate in the curriculum, develop and retain skills to
meet academic goals. Test scores are not viewed alone in determining the need for service but are
considered in the context of many other issues including, but not limited to; existing diagnosis,
neurological issues, functional developmental skill level, cognitive ability, specific educational goals
and objectives, and/or class placement. When a recommendation is made for therapy, the occupational
therapist and the Educational Team need to consider if support from an OT is necessary and required
for the student to access, participate and make progress in the educational setting. The Educational
Team needs to determine if the supports recommended by the OT require OT as an ongoing service,
or if these supports and accommodations could be implemented by other Educational Team members.
Occupational Therapy services can be provided through skill building sessions, classroom
collaboration, monitoring, consulting, or a combination of those modalities, depending on which
delivery model will best serve the needs of the student in the least restrictive environment.
Gemma is being assessed for occupational therapy as part of an initial assessment to determine
whether her needs significantly impact her academic performance within the realm of occupational
therapy. Occupational therapy eligibility and service frequency will ultimately be determined at the
time of the IEP meeting.

Evidence of Information
Gemma used verbal language as a mode of communication during assessments. The assessment was
completed in the OT room, in the general education classroom, on the playground and at lunch.
Assessments Administered:
 Records reviews
 Parent interviews
 Teacher interviews
 Observations
 Sensory Profile 2 School Companion (SP2)
 Developmental Test of Visual Perception (DTVP-3 or A)

Validity Statement
The assessor used a combination of assessment methods and tools to provide an authentic and
accurate profile of Gemma's learning style, preferences, strengths, and needs across environments and
settings. The assessor used this information to identify goal areas and identify supports and strategies
that are essential for her progress in her educational program. Results of this assessment are believed
to be a valid representation of her abilities.

Background and Presenting Concerns

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 CONFIDENTIAL REPORT
OCCUPATIONAL THERAPY EVALUATION
STUDENT'S LAST NAME FIRST NAME MI BIRTH DATE GENDER
Bettencourt Gemma 1.18.2008 Female

Gemma is a 10-year-old student currently attending Lake Ridge Academy in a 4th grade resource
classroom. Per current Individual Education Plan (IEP), Gemma's primary classification is under
Other Health Impairments (OHI). She has been receiving special education services including
Occupational Therapy, Speech Therapy, Academic Support and Counseling. Occupational therapy
services were implemented to address fine motor skills and sensory processing difficulties in the
classroom.
Gemma currently lives with her mom, dad, and brother. According to Ms. Bettencourt, her mother,
she receives private occupational therapy (OT) services. Gemma has a diagnosis of ADHD. She does
not have any allergies or history of surgeries. She is currently taking Ritalin for attention. She passed
her most recent hearing and vision screenings.
The assessor gathered data about Gemma's functional vision skills through informal observations. She
demonstrated the ability to track moving objects, diverge her eyes as an object moves farther away
and maintain focus on objects for an appropriate amount of time. She had difficulty converging her
eyes as an object moves closer. She often complains of blurred vision and headaches. She has been
observed to have difficulty concentrating, squinting and rubbing her eyes when reading or writing.
Due to her visual skills, she may demonstrate slow reading, difficulty reading and word and letter
reversals.
Jennifer is concerned with Gemma's ability to produce legible writing, keep up with academics, and
improve focus and attention.. Mrs. Jimenez, Gemma's teacher, reported that she is very social and has
lots of friends. She always wants to be the helper in the classroom and enjoys reading. Mrs. Jimenez
is concerned with her ability to produce written work. She reported that Gemma's handwriting is
difficult to read and she appears to be frustrated during writing tasks. She needs constant redirection
and verbal prompts for focus and attention during rug time and seated work.

OT Profile
Gemma likes to listen to music, dance, and watch YouTube videos and cartoons.. She stated that she
likes school because she can play with her friends. Her favorite subject is math because "it's easy".
She doesn't like writing because it's boring and her handwriting "isn't the best."
Gemma stated that she would like to be able to draw and write better and faster. Gemma wants to be
ballerina when she grows up. She learns best using a multi-sensory approach to learning.
The assessor gathered data about Gemma's class participation and in class supports through
observations, records review, and consultation with Gemma and Ms. Bettencourt. The teacher and
school staff have been supportive and accommodating to Gemma's needs. When necessary, she is
allowed to have movement breaks for self-regulation. A visual schedule is used for classroom
routines. She does not appear to be bullied at school. At home, she has a very supportive family.
Collaboration between therapists and staff has been poor which makes generalization to the classroom
more difficult. There has been inconsistent communication between school and family through email,
phone, or notes to update progress and/or address any concerns or comments. Homework takes too
long and is often not completed or returned.
Gemma participates in ballet class on Thursdays and gymnastics on Saturday mornings. In the
summer she plays in a soccer league but doesn't really care for it. Jennifer reported that Gemma has
irregular sleep patterns and often wakes up in the middle of the night.
Behaviors During Testing
The testing environment had visual distractions that affected Gemma's ability to focus on a given task.
She needed minimal verbal cues to transition between activities. She was able to follow written,
verbal and multi-step directions. She was able to answer and ask questions appropriately. Throughout

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 CONFIDENTIAL REPORT
OCCUPATIONAL THERAPY EVALUATION
STUDENT'S LAST NAME FIRST NAME MI BIRTH DATE GENDER
Bettencourt Gemma 1.18.2008 Female

the evaluation process, Gemma displayed an appropriate affect. She was able to maintain appropriate
eye contact during interactions with assessor. When participating in tabletop activities, she displayed
fair sitting posture. She needed moderate verbal prompts for focus due to difficulty maintaining visual
attention and following verbal directions.

Motor Skills / Sensory Motor Development

Playground Access
Gemma is able to safely navigate the play structure at recess. Demonstrating balance and
coordination, she was able to climb a ladder up and down, use the slide, climb on the monkey bars
and use the steps. She was observed playing soccer with her friends at recess.
Physical Education (PE) Access
Assessor consulted with Gemma's PE teacher and observed her in class. Her participation in PE is
impacted by her ability to pay attention. Gemma is able to hop on each foot, gallop, coordinate
jumping jacks, kick a moving ball and throw a ball accurately.
Classroom, Campus Navigation
Gemma was able to safely navigate the various surfaces at school including, concrete, dirt and steps.
At school, she is able to find needed items, move around obstacles such as chairs or desks, stand and
walk in a line with peers and locate rooms (office, nurse, bathroom). She was observed to be able to
transition around campus while carrying small items, a backpack and a lunch tray in the cafeteria.
Postural Skills for Educational Activities
In the classroom, Gemma's chair and desk are the appropriate height, accessible and in a functional
location. She frequently changed positions during seated work. When sitting on the floor, she
frequently changed positions but maintained personal space.
Classroom Tool Use
Gemma uses a functional right-handed grasp when completing fine motor activities such as writing,
coloring, and drawing. During pen to paper tasks, she displayed a dynamic tripod grasp and adequate
pencil pressure. Her thumb and finger make an open web space reducing the amount of pressure
needed to hold onto the pencil, which may translate into decreased hand fatigue. Using her opposite
hand, Gemma automatically stabilized the paper. She is able to use scissors independently. She can
cut simple geometric shapes (circle, square, triangle) and irregular complex shapes. She was able to
manipulate a stapler, tape dispenser and pencil sharpener. When given a shape to color, Gemma
colors 85-100% of the image. She is able to color an image with minimal (<3) deviations (1/8" outside
of lines). She is able to draw a person with 12 recognizable parts. She is able to independently draw
squares, diamonds and circle.
Technology Accessibility
Gemma is able to use a keyboard, navigate a mouse, access applications or programs on a computer
and use a tablet or iPad. She was able to use the hunt and peck method to locate letters on the
keyboard to type. She reported that she prefers typing to writing. It is recommended that Gemma use a
word processor for written output when necessary. She can type 15 words per minute (wpm).
Written Expression
Gemma has demonstrated the ability to produce legible written work but does not do it consistently.
Compared to her peers, Gemma tends to write too slowly which can impact her output. When writing,

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 CONFIDENTIAL REPORT
OCCUPATIONAL THERAPY EVALUATION
STUDENT'S LAST NAME FIRST NAME MI BIRTH DATE GENDER
Bettencourt Gemma 1.18.2008 Female

she is able to identify where to start and stop on writing paper, write from left to right, work top to
bottom and generate her own ideas. From memory, Gemma is able to independently print the upper
and lower case letters of the alphabet (letters could be identified as the intended letter). She is able to
independently write the numbers 1-10. Her writing has inconsistent spacing, letter formation and line
orientation. She is able to copy from near sight (90% accuracy) and far sight (85% accuracy). When
copying, Gemma would often miss punctuation and not use capital letters properly.
Developmental Test of Visual Perception (DTVP-3 or A)
The DTVP-3 is a battery of 5 subtests that measure different but interrelated visual perceptual and
visual motor abilities. It allows for a comparison between motor reduced visual perception and visual
motor skills. Scaled scores that are 13 and above reflect above average ratings; scores between 8-12
reflect average ranges; 6-7 reflects below average and 5 and below reflect poor rating. Scores are as
follows:

Subtest Description Scaled Scores Percentile Description

(SS) (Average of Statistics
8-12)
Eye-Hand Coordination 5 5 Poor
Children are required to draw precise straight or
curved lines in accordance with visual boundaries.
Copying 9 37 Average
Children are shown a simple figure and asked to draw
it on a piece of paper. The figure serves as a model for
the drawing.
Figure-Ground 9 37 Average
Children are shown stimulus figures and asked to find
as many of the figures as they can on a page where
the figures are hidden in a complex, confusing
background.
Visual Closure 5 5 Poor
Children are shown a stimulus figure and asked to
select the exact figure from a series of figures that
have been incompletely drawn. In order to complete
the match, children have to mentally supply the
missing parts of the figures in the series.
Form Constancy 11 63 Average
Children are shown a stimulus figure and asked to
find it in a series of figures. The targeted figure will
have a different size, position, and/or shade, and it
may be hidden in a distracting background.

Composite Percentile Description of

Index Index
(Average 90-
100)
Overall General Visual Perception Index = 82 12 Below
Average

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 CONFIDENTIAL REPORT
OCCUPATIONAL THERAPY EVALUATION
STUDENT'S LAST NAME FIRST NAME MI BIRTH DATE GENDER
Bettencourt Gemma 1.18.2008 Female

Motor Reduced Visual Perception Index = 90 25 Average

Visual Motor Integration Index = 87 19 Below
Average

Gemma was able to complete the standardized assessment in the appropriate time frame. She
demonstrated a strength in the Motor Reduced Visual Perception area as evidenced by her scores.
When copying shapes from near sight, she was able to use smooth and fluid lines. Gemma was able to
identify specific figures within a cluttered and complex background. She demonstrated the ability to
match two figures that vary on one or more discriminating features (i.e. size, position, or orientation).
Gemma displayed a significant delay in her Visual Motor Integration Skills. She had difficulty
drawing straight and curvy lines within visual boundaries. She was not able to recognize a stimulus
figure that was not completely drawn. Due to these weaknesses, Gemma may reverse letters, numbers,
or words when copying or writing, have poor recall of visually presented material and/or have
difficulty copying from the board. Her short attention span during testing may have impacted her
scores. Her scores appear to be a good indicator of her functional abilities. Although she demonstrated
weaknesses, she is still able to produce legible and functional written work.

Social / Emotional / Behavior Skills

Social Participation in School Environments
Gemma will respond to her peers and adults. She often initiates interactions with peers. Teacher
reported that Gemma is very friendly and nice to all of her peers. She has many friends. Parent
reported that Gemma enjoys playing with her cousins and her neighbors. She participates in several
organized sports and has recently joined the Girl Scouts. At recess, she usually plays with her peers.
She was able to transition between classrooms. She respects other people's personal space. She will
play games independently. During group activities, Gemma is able to follow rules, interact with peers,
tolerate losing, take turns and share materials.
Emotional Regulation for School Participation
Gemma is a pleasant and cooperative student. She is able to express her needs and wants. When
asked, she is able to describe her own emotional or physical status. She has demonstrated a low
frustration tolerance but is easily redirected. She responds well to verbal and visual supports to help
keep her calm and focused during the day. Gemma tends to use various self-regulation strategies to
keep engaged at school, such as heavy work, sensory diet and movement breaks. Heavy type work
activities include carrying items, taking down/putting up chairs, or performing jobs for the teacher
(e.g. three hole punch, stapler, etc.).

Sensory Processing
Sensory processing is the brain's ability to orient, regulate, and use multi-sensory information to
successfully complete activities and make the appropriate adjustments to assure ongoing success.
Sensory processing skills help lay the foundation for a variety of behaviors and skills such as
emotional affect, the ability to maintain focus and attention, fine motor and visual motor skills, and
the ability to transition between activities.
Sensory Profile 2 School Companion (SP2)
The SP2 is a questionnaire used to gather information about a child's ability to adapt to/cope with
basic sensory input, grouping them into sensory processing systems: auditory, visual, touch,
movement, body position, and oral. These patterns may affect student's ability to function, participate,

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 CONFIDENTIAL REPORT
OCCUPATIONAL THERAPY EVALUATION
STUDENT'S LAST NAME FIRST NAME MI BIRTH DATE GENDER
Bettencourt Gemma 1.18.2008 Female

and perform within school, home, and/or community environment. It is meant to complement with
other clinical observations/tools, and the scoring should be taken within the context of all information
gathered. There are different norm referenced, standardized caregiver and/or teacher questionnaires,
ranging from infancy through school age.
Caregivers and/or teachers rate behavioral statements on a 5-point Likert scale and scoring is looked
at in terms of Typical Performance, Probable Difference, and Definite Differences.

Section Raw Score Typical Functioning Range Interpretation

Auditory 26/35 6-15 Much More Than Others
Visual 31/35 6-17 Much More Than Others
Touch 14/40 5-15 Just Like the Majority of Others
Movement 17/40 6-17 Just Like the Majority of Others
Behavioral 27/55 9-22 More Than Others

Quadrants Raw Typical Functioning Interpretation

Score Range
Seeking/Seeker 28/40 7-19 Much More Than Others
Avoiding/Avoider 20/60 8-21 Just Like the Majority of
Others
Sensitivity/Sensor 28/55 10-23 More Than Others
Registration/Bystander 13/65 10-28 Just Like the Majority of
Others
Sensory Pattern/Quadrant Summary:
 Seeking/Seeker -- "obtains"; finds interest and pleasure in sensations
 Avoiding/Avoider -- "bothered by"; necessity to control or avoid sensation
 Sensitivity/Sensor -- "detects"; ability to acutely notice sensations
 Registration/Bystander -- "misses"; general awareness of sensations
Our sensory threshold is an indication of how much input it takes to activate our system responses. A
low threshold indicates that it does not take much to activate. Sensory sensitivity behaviors are acting
in accordance to our threshold, and sensory avoiding behaviors are acting to counteract the threshold.

Raw Score Typical Functioning Range Interpretation

School Factor 1 37/65 10-28 More Than Others
School Factor 2 35/50 10-24 More Than Others
School Factor 3 35/60 9-23 Much More Than Others
School Factor 4 15/45 6-16 Just Like the Majority of Others
 School Factor 1: Supports - measures a student's need for external supports to participate in
learning; often a high amount of sensory input is needed to get ready for learning.
 School Factor 2: Awareness - measures the student's awareness and attention within the
learning environment; often these students are pulled away from learning due to other stimuli
in the room.

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 CONFIDENTIAL REPORT
OCCUPATIONAL THERAPY EVALUATION
STUDENT'S LAST NAME FIRST NAME MI BIRTH DATE GENDER
Bettencourt Gemma 1.18.2008 Female

 School Factor 3: Tolerance - measures the student's tolerance within the learning
environment, no longer distractible but avoidant behaviors or hypersensitivity.
 School Factor 4: Availability - measures the student's availability for learning within the
environment as it relates to disengagement due to avoidant behavior or failure to detect
important stimuli to then learn.

Mrs. Jimenez, Gemma's teacher, completed the questionnaire.

Touch
The tactile system, or touch system, refers to stimulation reaching the central nervous system from
receptors in the skin.
Occasionally, Gemma may react to various tactile experiences negatively. She constantly fidgets with
objects.
Balance and Motion (Movement)
Through receptors located in the inner ear, the vestibular system provides information on the position
of the head in relation to gravity and influences posture, balance, and coordination.
Gemma appears to be able to demonstrate balance, movement, and postural control appropriately. She
plays or fiddles with objects, can be fidgety or disruptive when close to other people and slower to
participate in physically active tasks.
Hearing (Auditory)
The auditory (hearing) system processes sound information. Auditory discrimination is the ability to
differentiate between various important and un-important sounds within the environment.
Gemma demonstrates consistent reactions when processing auditory stimuli. She does not respond to
her name being called. She frequently misses verbal directions and has difficulty participating in
group activities where there is a lot of talking.
Visual
The visual system uses the eyes to receive information and interprets what is seen.
Gemma demonstrates consistent reactions when processing visual information. She misses written
directions, watches people move around the room and leaves items blank on a busy worksheet, despite
knowing the answer.
Behavioral Responses
Behavioral responses are the actions of a person, usually in relation to their environment.
Gemma has difficulty understanding and processing sensory information, which can produce
inappropriate responses in everyday life. She does things in a harder way than is needed and
demonstrates poor frustration tolerance.
Gemma's scores may be elevated or impacted by unrelated sensory processing issues such as medical,
developmental, or cognitive reasons. Gemma has a diagnosis of ADHD. Students with ADHD can
demonstrate sensory behaviors. These actions can be caused by inattention and not by the
environment.
Based on the results from the Sensory Profile 2, Gemma appears to be a Seeker (finds interest and
pleasure in sensations), Avoider (necessity to control or avoid sensation), Sensor (ability to acutely
notice sensations) and Bystander (misses or appears not to detect sensory information). Due to her

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 CONFIDENTIAL REPORT
OCCUPATIONAL THERAPY EVALUATION
STUDENT'S LAST NAME FIRST NAME MI BIRTH DATE GENDER
Bettencourt Gemma 1.18.2008 Female

difficulty in understanding some sensory information, Gemma may demonstrate behaviors that impact
her ability to function within her environment. She demonstrates behaviors that add more intense
sensation such as chewing on clothing, fidgeting, or constantly moving around. Gemma can be easily
overstimulated. She is drawn to or distracted by stimuli in environment. She can appear introverted or
lack the motivation to participate in activities. These behaviors can impact her ability to make and
maintain friendships, initiate and complete tasks and complete worksheets. Gemma may benefit from
activities that incorporate multiple senses such as hands on activities or sitting on a therapy ball,
participating in "heavy work" activities and using fidgets or manipulatives.
All sensory processing preferences have advantages and disadvantages. There are no inherently good
or bad sensory processing preferences. The context of the environment, and the task at hand,
determine whether an individual’s sensory processing preferences are an advantage or disadvantage.
Therefore, we need to “consider if sensory processing is interfering with Student’s activities or
aspects of her activities of daily living are not satisfying to her” (Dunn 2002).

Adaptive Skills / Self-help Skills

School Activities of Daily Living (ADL)
School ADL's include grooming, hygiene, toileting, mealtime and clothing management as they relate
to participation in the student's educational environment.
The assessor gathered data about Gemma's ADLs through observations and consultation with Ms.
Jimenez and Ms. Bettencourt. She is able to use utensils for feeding, drink from a cup, open
containers at lunch or snack and manage her clothing before and after toileting at school
independently. She requires verbal and/or visual cues to wash her face and wash and dry her hands at
school. She requires physical prompts such as hand over hand or light touch to tie her shoe laces at
school.
School Instrumental Activities of Daily Living (IADL)
School IADL's include organization of personal materials (backpack, desk, cubby), safety awareness,
and learning communication devices such as phones and computer.
The assessor gathered data about Gemma's IADLs through observations and consultation with Ms.
Jimenez. She is independent in retrieving, gathering, and putting away her materials, safety
awareness, learning communication devices such as phones or computer and following her class
schedule/routines. Gemma requires verbal or visual support for managing her notebooks and papers
and keeping her desk organized.
Task Organization/Pre-Vocational Job Skills
The assessor gathered data about Gemma's vocational skills through observations and consultation
with Ms. Jimenez. She is able to initiate tasks and follow written or verbal directions independently.
She requires verbal and/or visual cues to attend to tasks and complete multi-step activities in an
appropriate time frame.
Vocational/Life Skills
Gemma demonstrates the ability to twist, bend, reach, carry items and grasp items in her environment
safely and easily. Her attention impacts her ability to participate in vocational activities and may
require modifications.
Self-Advocacy

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 CONFIDENTIAL REPORT
OCCUPATIONAL THERAPY EVALUATION
STUDENT'S LAST NAME FIRST NAME MI BIRTH DATE GENDER
Bettencourt Gemma 1.18.2008 Female

The assessor gathered data about Gemma's self-advocacy skills through observations and consultation
with Ms. Jimenez and Ms. Bettencourt. She demonstrates good self-advocacy skills. She is able to
raise her hand to ask a question, stick up for herself, express her needs and wants clearly and seek out
help from peers or adults when necessary.

Summary
Gemma is a pleasant and cooperative student. She demonstrates a relative strength in the areas of
playground access, postural skills for educational activities, movement skills for vocational activities,
classroom tool use, technology accessibility and social participation. She appears to have functional
range of motion and strength for the educational setting. She participates in PE to the best of Gemma's
ability. She is able to navigate her school environment and find classrooms and offices. She is able to
raise her hand to ask questions and express her needs and wants.
Currently, there are several modifications and accommodations being implemented throughout
Gemma's school day, which allows her to access her educational environment as it relates to written
expression and emotional regulation. These strategies include heavy work, movement breaks,
modified paper, graphic organizers, and token reward system. She appears to be benefiting from most
of these strategies but she continues to need support.
Gemma's difficulties in the areas of written expression and emotional regulation affect her ability to
engage in structured learning activities at school. Gemma scored in the Very Poor Range on the
Visual Motor Integration Section of the DTVP-3 which can impact her ability to copy from the board
and produce legible work. She continues to have difficulty writing the alphabet from memory and can
be easily frustrated. Gemma can successfully use and understand some sensory information, and has
difficulty understanding and using other sensory information. On the Sensory Profile 2, she scored in
the Definite Difference/Much More than Others in the School Factors 1 and 3. She scored the
Probable Difference/More Than Others in School Factor 2 and 4. Gemma would need extra sensory
input throughout the day to get her sensory needs met. At this time, occupational therapy services are
recommended to address the areas of need mentioned above. As Gemma's functional participation
improves it is anticipated that occupational therapy will be discontinued unless additional needs are
identified by the individual education program team.

Recommendations
 Allow Gemma extra time with written assignments.
 Allow Gemma to use a word processor for written output.
 Use graphic organizers.
 Use modified paper such as graph paper, raised line paper, or enlarged paper.
 Multi-sensory approach to writing in therapy sessions
 Allow frequent movement breaks to help with regulation including many "heavy type work"
activities such as carrying the lunch cart, running books back to the library, taking
down/putting up chairs at the beginning/end of the day and performing jobs for the teacher
(e.g. three-hole punch, stapler, etc.).
 Allow Gemma to stand instead of sit at her desk.
 Provide positive reinforcement.
 Provide short breaks when refocusing is needed.
 Provide Gemma with frequent movement breaks throughout the day (especially during
extended reading/writing activities) in order to improve overall attention, focus and provide a
visual "break" (classroom).
 Use two different colored shoe laces for shoe tying.
 Allow extra time for task completion.

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 CONFIDENTIAL REPORT
OCCUPATIONAL THERAPY EVALUATION
STUDENT'S LAST NAME FIRST NAME MI BIRTH DATE GENDER
Bettencourt Gemma 1.18.2008 Female

 Explore strategies for organizing desk materials (such as use of a desk organizer, a visual
"map" of where materials go, and/or a desk "buddy" to help.
 Break down tasks into manageable units.
 Use of checklists
 Visual demonstrations

Signature: _______________________________________ Date: _______________

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