Comprehensive Evaluation

An initial evaluation begins on my end with a review of referral information provided by the diagnosing provider and any therapy notes from current treatment. I also review an OT-specific case history, neurodevelopmental profile, sensory processing checklist, and social-emotional growth chart that is available for you for you to complete and submit on my client portal prior to the first visit. When you arrive for evaluation, you can expect it to take 60-90 minutes on average, and I encourage parents to be present for the duration. Siblings are asked to remain at home, or in the waiting area if they are old enough to do so without direct supervision. In order to keep my commentary and note-taking to a minimum and to preserve my interaction with your child, I videotape the evaluation for the purposes of review later by myself, as well as at the follow up first visit with you as needed. My evaluations consist primarily of caregiver interview and structured clinical observation, as I focus on functional participation in activities more than scores. Your child will be asked to perform a variety of movement tasks on various pieces of equipment and, therefore, should be dressed in comfortable clothing, shorts and short-sleeve shirts preferred, so please bring some along if the weather prohibits wearing the same. I do request that shoes be removed as well. Socks will be available in the event you forget to bring some, and accommodations can be made for children who don’t tolerate socks at this time. In addition to the videotaping, I also take still pictures of standing and sitting posture from several angles. Again, these are utilized solely for the purpose of assessment and review with you. Minimal physical contact with the child is necessary except as needed to help with certain observations of righting and equilibrium reactions, to assess strength, and to assist with positioning, or for safety on equipment. The areas I am assessing include nervous system arousal state, sensory modulation, emotional regulation, sensory processing, engagement and play skills, focus and attention, reflex integration, postural control, strength and endurance, motor planning, bilateral coordination, visual perception, visual motor integration, grasp of objects and tools, and fine motor coordination. I may also assess oral motor skills if that is an area of concern, and I do request that families bring along both preferred and non-preferred foods and liquids of various consistencies for consumption during the assessment. I also request that caregivers complete a food diary and inventory. Additionally, I have caregivers complete an occupational performance measure to help identify goals or priorities for treatment.