1. Introduction with pertinent site information (e.g. type of setting, context, pediatric client population, etc.)

1. Client information and his/her situation (e.g. initials; age; dates of onset and referral; reason for OT referral; prior health status; prior occupational performance/ participation status and patterns; contextual information). TO PRESERVE CLIENT CONFIDIENTIALITY, AVOID USING THE CHILD’S ACTUAL INITIALS. (GR is a 4 year old boy diagnosed with autism, low tone, behavioral disruptive behavior, and sensory disorder. His psychosocial issues are frustration, anxiety, isolation, behaviors such as kicking, screaming, and hitting, and depression. He has difficulty with gross motor, coordination, dressing, toileting, and self-feeding tasks.
2. A brief summary of the child’s OT-related problems, goals, evaluations, interventions and intervention rationales. Concisely include assessment tools/ methods that were used, treatment activities and their associated goals (summarized), and the therapeutic relationship with the child and his/her family. Include relevant cultural information (including language issues if relevant).
3. OT Theories/ Frames of Reference (FOR) - including one psychosocial theory or FOR - as associated with the client’s current OT interventions and the related intervention rationales. Include a brief statement about the expected impacts of incorporating these theories or FORs. Name the originator(s) of any theory you mention, with no need to cite and reference any sources.
4. The child’s and family’s perception of his/her illness and psychosocial limitations (see Pediatric Case Study Template). Information can be gleaned from observations of therapist-child interactions (and therapist-family interactions, if applicable), consultation with the treating therapist(s), and/or your informal interview of the child and/or family member(s) (when feasible and appropriate).
5. The family’s/ child’s social network and social interaction opportunities; the child’s favorite activities; his/her most challenging occupationally-based activities and why they are difficult; related issues that will impact post-discharge expectations for this child’s life situation.
6. The length, structure and funding for OT services for this child at the facility; the child’s and family’s social support network after discharge; the child’s discharge environment including accessibility barriers, if applicable; changes to the discharge environment recommended by the client’s current OT, if applicable.
7. A brief summary that includes your judgments regarding the value of this case study for informing OT practice. Also include concise suggestions for improving OT services for this child (e.g. to make them more culturally sensitive). 2-3 pages