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pediatric evaluation form

Last post 02-28-2018, 10:17 AM by Amanda Basta. 133 replies.
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  •  07-27-2011, 3:02 PM

    Re: pediatric evaluation form

    I was just wondering if you received the eval form template. I have not yet received it. If you did get it, could you please e-mail it to

    Thank you very much!

  •  08-12-2011, 3:28 PM

    Re: pediatric evaluation form

    I do evaluations for children turning 3 are being evaluated to transition between EI and CPSE. This is what I use:



    Child’s Name:                                                            Evaluator:

    Date of Birth:                                                             Date of Evaluation:

    Current Age: ( ) months                                              Location:  


    Tests Administered: Grasping and Visual Motor Integration sections of Peabody Developmental Motor Scale, HELP Checklist, (Sensory Profile if Sensory Processing was a major initial concern), Clinical Observation and Parent Report.

    Medical History: (Name) was evaluated on (this noted date) at (location) to determine need for occupational therapy services through the CPSE program. Describe medical and developmental history. See Psychosocial Report for detailed social history.

    General Behavior: (Name) presented as ...describe behavior during evaluation and any parent concerns relating to behavior.

    Sensory Processing: Sensory processing relates to how an individual uses his or her senses to process information from his or her surroundings, interpret this information, then provide an adaptive response. Sensory information can be received through the following systems: tactile (touch), vestibular (movement of head in space), proprioceptive (muscles and joints), gustatory (taste), olfactory (smell), visual, and auditory.  

     (Name) ...describe sensory processing as seen during evaluation, parent concerns, and results of Sensory Profile if administered.


    Range of motion (amount of movement at a joint) describe

    Righting & equilibrium reactions (maintain an upright posture with the head & neck keeping alignment with the trunk when the base of support is challenged) describe

    Postural control (the ability to assume & maintain postures during static & dynamic activities)  describe

    Fine Motor and Visual Motor: Fine motor and visual motor performance were formally assessed by the Peabody Developmental Motor Scale. The two domains that were tested by this evaluator were “Grasping” and “Visual Motor Integration.” (Name)’s raw score for the Grasping section was a , ranking him in the  th percentile, performing at an age equivalent of   months, which is a  % delay. The raw score for the Visual Motor Integration section was  , ranking him in the  th percentile, performing at an age equivalent of   months, which is a  % delay.

     The Peabody was completed seated at tabletop. Describe skills

     Gross Motor: Describe general impressions. See Physical Therapy report for more detailed gross motor assessment.

     Cognitive/Perceptual: Describe impressions

    Self Help: Describe skills

    Summary and Recommendations: (Name) was evaluated at (location) to determine his qualification for occupational therapy services in the CPSE program. As per the Peabody Developmental Motor Scale, Name presents with  % delay in grasping skills, and a  % delay in visual motor integration skills compared to the normative sample of his peers. Further assessment through clinical observation is consistent with these findings. Describe additional important details

    GoalsWrite CPSE OT goals if services are approved. 


    Upon completion of the evaluation, this clinician’s initial impressions & recommendations were discussed with the caregiver.  Any questions and concerns regarding the evaluation & the child’s development were addressed.  The caregiver agreed with the findings & recommendations offered by this clinician.  The caregiver stated that the child’s general performance & behavior were typical on this day.


    The provision of the related services recommended above will be determined at the CPSE district meeting.


    “I certify that I personally evaluated the above named child, employed age appropriate instruments & procedures as well as informed clinical opinion.  I further certify that the findings contained in this report are an accurate representation of the child’s level of functioning at the time of the assessment.”

                                                                                                   Signature, Name, Credentials, Date

  •  08-31-2011, 11:07 PM

    Re: pediatric evaluation form

    I work in a pediatirc therapy clinic and would LOVE to have you share your templates.  My e-mail address is  Thank you!


  •  09-04-2011, 10:46 PM

    Re: pediatric evaluation form

    I work in a school system and would love to have your templates. Thankyou for sharing ! Debby
    Deb B OTR/L
  •  09-04-2011, 10:49 PM

    Re: pediatric evaluation form

    Here is my email: the above post, Debby
    Deb B OTR/L
  •  09-05-2011, 10:01 PM

    Re: pediatric evaluation form

    Hi Everyone, 

    I am just now starting a school based practice after years in Early Intervention. I would love a copy of the evaluation template if someone could email it to me. Thanks for sharing resources it's a tremendous help!


  •  10-04-2011, 8:42 AM

    Re: pediatric evaluation form


    Hi there. I was looking for examples of pediatric evaluations and come across this post. If you still have the templates to some of your pediatric evaluations and willing to share with me I would be greatly appreciative! I am currently trying to start a new outpatient pediatric program at our hospital. My email is

    Thanks so much!

    Stephanie Wright

  •  10-11-2011, 5:06 PM

    Re: pediatric evaluation form


    I saw a bunch of people trying to get your ped eval form

    I would like to get one as well if you don't mind

    My email is

    Thank you so much,

    Jin Kim

  •  10-30-2011, 8:03 PM

    Re: pediatric evaluation form

    Hi Lindsey, Do you still have the copy of the pediatric evaluation form. If you do can I please have a copy? I need a template that can speed up the amount of time I spend writing evaluations.
  •  11-10-2011, 7:53 PM

    Re: pediatric evaluation form

    Hi Libby,

    I was searching online for sample evaluation formats to update what I am presently using.  I know your post was a while ago but was hoping this would still reach you.  You are very generous to offer your templates.  If it is at all possible  that you send your templates to me I would be so grateful.  Thank you so much.



  •  12-12-2011, 10:30 PM

    Re: pediatric evaluation form

    Please send me your email and I can send you many educational templetes.


    Clovis, California
  •  01-19-2012, 9:00 PM

    Re: pediatric evaluation form

    I'm trying to revamp my early intervention evaluation form and would love to see what another practitioner is currently using. I was doing more EI treatments and now am beginnng to evaluate more often.

    Thanks for sharing your resources it is greatly apprecaited!

  •  02-15-2012, 9:02 AM

    Re: pediatric evaluation form


    My email is  Any forms you are willing to share would be greatly appreciated!

    Thank you!


  •  03-16-2012, 12:37 PM

    Re: pediatric evaluation form


    I am especially interested in your forms for older students. Could you please email me also. please,please,please  

  •  09-12-2012, 4:11 AM

    Re: pediatric evaluation form


    plz forward if you got the pediatric evaluation form


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