ESY Information Sheet

ESY OT/PT Student Information Sheet

ESY Information Sheet For YR. Therapist Sending Information: Student Information Student: Birthdate: School Attended/Program: ESY Therapy Service Time: OT PT GOALS ATTACHED: Relevant Medical Info : Seizure Precaution Fall Precaution Sun Protection due to Medication Cardiac Concerns (explain) _____ Respiratory Concerns (explain) G-Tube Trach Catheter Other: ______Equipment You Are Sending ( Please label equipment for ESY and for fall program on MV ESY label) : (please attach written program, if available) Hand Splints: Benik R/L Other: R/L Orthotics: SMO R/L AFO R/L Serial Casting: UE R/L LE R/L Ambulation Devices Gait Status: Transfer Status: Gait Belt Walker(s) ______Type of Stander ______Time in Stander: ______Seating/Positioning W/C : ______Classroom Chair: Mat Program: ______Other Equipment: ______Sensory Materials Move-n-sit Cushion Thera-band Weighted Vest Weighted Lap Pad _ Chew items ______Bear Hug Vest Other Vest Sensorimotor Strategies: ______Writing/Assistive Technology Pencil Grasp Slant Board Lined Paper Writing Program Keyboarding Program Switches Other information to support the student ______

Number to contact you during the summer months if there are question regarding the student’s therapy: ______

GOALS ATTACHED Revised 2/12 - K. Kein