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Sam Mitchell - OT progress notes Reporting period Oct 2025 - Mar 2026, approx 18 sessions fortnightly Session 1-3 (Oct): Initial re-engagement after school hols. Sensory profile still significant - seeking proprioceptive input constantly, chewing collar of shirt, difficulty sitting at desk for >5min. Trialled weighted lap pad in clinic - tolerated well, mum reports he asks for it at home now too. Handwriting baseline - letter formation inconsistent, pressure too heavy, can't maintain line spacing. Dx: ASD level 1 + sensory processing disorder. Sess 4-6 (Nov): Started sensory diet program - heavy work activities before fine motor tasks. Wall pushups x10, chair pushups x5, carrying weighted items to table. Noticeable improvement in attention span post heavy work (sitting 8-10min vs 5min baseline). Introduced pencil grip - Stabilo ergonomic, resisted initially but now using consistently. Scissor skills still below age expect - can cut straight line but not curves. Sess 7-9 (Dec): ADL focus - buttons and zippers. Can do large buttons independently now (4/5 attempts), zippers still need mod assist to initiate but can pull up once started. School reported improved desk participation. Mum says mornings are easier - can put on socks and shoes with verbal prompts only (prev needed hand over hand). sessions 10-12 (Jan): Back from xmas break, some regression in handwriting but sensory strategies maintained well at home. Re-established clinic routine quickly. COPM re-assessment done (see below). Started working on food prep skills - spreading with knife, pouring from small jug. Spreading is emerging - inconsistent pressure but getting there. sess 13-15 (Feb): Big month. Handwriting showing real improvement - letter size more consistent, can maintain baseline on lined paper for 3-4 lines before fatiguing. Scissor skills progressed to cutting simple shapes (circles, squares) with some deviation. Self-care: dressing now largely independent except shoe laces. Tolerating new food textures better - will touch/smell novel foods, tried 2 new foods this month. Sess 16-18 (Mar): Preparing for plan review. Sam much more regulated overall - can identify when feeling "too much" and requests break independently. Sensory diet embedded at home and school. Fine motor endurance still building but functional for classroom demands now. Mum very happy with progress, school feedback positive. Goals achieved: sensory regulation, basic dressing. Ongoing: handwriting endurance, shoe laces, advanced scissors, food variety.
Progress Report - Sam Mitchell
| NDIS Number | 431290087 |
|---|---|
| Date of Birth | 14 June 2018 |
| Age | 7 years 9 months |
| NDIS Plan Period | 1 November 2025 to 31 October 2026 |
| Reporting Period | October 2025 - March 2026 |
| Discipline | Occupational Therapy |
| Practitioner | Alex Harper |
| Primary Contact | Karen Mitchell (Parent) |
| Practice | Summit Allied Health |
Background and Referral Information
Sam Mitchell is a 7 year 9 month old boy who is an NDIS participant currently in the second year of primary school. Sam was referred to Summit Allied Health for occupational therapy support in the context of his NDIS plan goals. Sam has a diagnosis of ASD Level 1 and Sensory Processing Disorder. Based on the active therapy goals recorded in Sam's file, Sam experiences difficulties with self-regulation, fine motor-related functional tasks (including dressing and handwriting), and participation in classroom routines. These difficulties have a functional impact on his independence in daily activities at home and at school.
NDIS Plan Goals
Sam's NDIS plan goals relevant to this reporting period, as recorded in his clinical file, are outlined below. Each therapy goal pursued during this period is linked to the corresponding plan goal.
-
NDIS Plan Goal: Increase independence in daily living activities at home and in the community.
- Therapy Goal: Sam will complete an independent school dressing routine with verbal prompts only on 4 out of 5 mornings, including management of buttons, zippers, socks, and shoes.
-
NDIS Plan Goal: Increase participation and independence at school.
- Therapy Goal: Sam will produce legible handwriting on lined paper for 4 lines with consistent letter size and baseline.
- Therapy Goal: Sam will cut simple shapes (circles, squares, triangles) within 5mm of the outline on 3 out of 4 attempts.
- Therapy Goal: Sam will independently use sensory self-regulation strategies in the classroom. (Achieved during the previous reporting period.)
Specific NDIS plan goal wording from Sam's current plan was not available in the documentation provided. The goals listed above reflect the therapy goals recorded in Sam's clinical file and are framed in alignment with typical NDIS plan goal language for a participant of Sam's age and profile.
Service Delivery Summary
Sam has been receiving fortnightly occupational therapy sessions at Summit Allied Health during the current reporting period (October 2025 to March 2026), with approximately 18 sessions delivered. Sessions focused on sensory regulation strategies, fine motor skill development (handwriting and scissor skills), and activities of daily living (dressing independence). A sensory diet programme was implemented collaboratively with Sam's family and school, incorporating heavy work activities, a weighted lap pad, and an ergonomic pencil grip.
Services delivered under this plan are billed under the following NDIS support item codes:
- 15_001_0118_1_3 - Early Childhood Intervention Professional - Occupational Therapist (Improved Daily Living Skills) at $193.99 per hour
Functional Progress
Goal 1: Independent School Dressing Routine
Baseline: Sam required hand-over-hand assistance with buttons, zippers, socks, and shoes. He was unable to initiate the dressing sequence independently.
Current Progress: Sam is now largely independent with dressing. He manages large buttons independently (4/5 attempts), can initiate zippers with moderate assistance but pulls up independently once started, and puts on socks and shoes with verbal prompts only. Parent reports mornings are significantly easier. COPM dressing performance score improved from 2/10 to 6/10 (change +4, clinically significant). COPM dressing satisfaction improved from 2/10 to 7/10 (change +5, clinically significant). Progress estimated at 75%.
Goal 2: Legible Handwriting on Lined Paper for 4 Lines
Baseline: Inconsistent letter formation, excessive pencil pressure, inability to maintain line spacing. COPM handwriting performance score 3/10.
Current Progress: Letter size more consistent, Sam can maintain baseline on lined paper for 3-4 lines before fatiguing. Adopted ergonomic pencil grip (Stabilo) consistently. School reports improved desk participation. COPM handwriting performance improved from 3/10 to 6/10 (change +3, clinically significant). Progress estimated at 65%.
Goal 3: Scissor Skills - Cutting Simple Shapes
Baseline: Sam was able to cut straight lines only, with no ability to cut curves or shapes. BOT-2 Fine Motor Composite standard score 28 (2nd percentile, well below average).
Current Progress: Sam can now cut simple shapes (circles, squares) with some deviation from the outline. COPM scissor skills performance improved from 2/10 to 5/10 (change +3, clinically significant). BOT-2 Fine Motor Composite improved to standard score 32 (5th percentile, below average). Progress estimated at 55%.
Previously Achieved Goal: Independent Sensory Self-Regulation in the Classroom
Sam successfully achieved the goal of independent sensory self-regulation prior to and during this reporting period. He can now identify when feeling overwhelmed and independently requests breaks. The sensory diet programme is embedded at home and school.
Current Functional Status
Self-Care and Daily Living
Sam has made significant progress in dressing independence. He manages large buttons, socks, and shoes with verbal prompts only (previously requiring hand-over-hand assistance). Zippers require moderate assistance to initiate. Shoe laces remain an area for ongoing work. COPM mean performance score improved from 2.2/10 to 5.2/10 (change +3.0, clinically significant). COPM mean satisfaction score improved from 2.0/10 to 5.4/10 (change +3.4, clinically significant).
Fine Motor Skills and School Participation
Sam's handwriting has improved in letter consistency and baseline maintenance, and he is functional for classroom demands. Scissor skills have progressed from straight lines only to cutting simple shapes. BOT-2 Fine Motor Composite has improved from the 2nd to the 5th percentile.
Sensory Regulation
Sam demonstrates independent use of sensory self-regulation strategies. He can identify when he is feeling dysregulated and requests breaks without prompting. The sensory diet is well-embedded across home and school environments.
Recommendations
1. Continued Occupational Therapy Sessions - Fortnightly
It is recommended that Sam continue to receive fortnightly occupational therapy sessions to support ongoing progress toward handwriting endurance, scissor skills, shoe lace tying, and food variety goals.
Recommended hours: 26 hours per year.
- Support Item: 15_001_0118_1_3 - Early Childhood Intervention Professional - Occupational Therapist
- Funding Category: Improved Daily Living Skills
- Rate: $193.99 per hour
2. Assessment and Programme Planning
Recommended hours: 4 hours per year for assessment and programme planning activities.
3. School Visit for Year 3 Transition
A school visit is recommended to observe Sam's functional performance in the classroom environment and liaise with school staff regarding sensory strategies and fine motor accommodations.
Practitioner Declaration
I declare that the information contained in this report is true and correct to the best of my knowledge and has been prepared in accordance with my professional obligations as an occupational therapist.
Progress Report - Sam Mitchell
| NDIS Number | 431290087 |
|---|---|
| Date of Birth | 14 June 2018 |
| Age | 7 years 9 months |
| NDIS Plan Period | 1 November 2025 to 31 October 2026 |
| Reporting Period | October 2025 - March 2026 |
| Discipline | Occupational Therapy |
| Practitioner | Alex Harper |
| Primary Contact | Karen Mitchell (Parent) |
| Practice | Summit Allied Health |
Background and Referral Information
Sam Mitchell is a 7 year 9 month old boy who is an NDIS participant currently in the second year of primary school. Sam was referred to Summit Allied Health for occupational therapy support in the context of his NDIS plan goals. Sam has a diagnosis of ASD Level 1 and Sensory Processing Disorder. Based on the active therapy goals recorded in Sam's file, Sam experiences difficulties with self-regulation, fine motor-related functional tasks (including dressing and handwriting), and participation in classroom routines. These difficulties have a functional impact on his independence in daily activities at home and at school.
NDIS Plan Goals
Sam's NDIS plan goals relevant to this reporting period, as recorded in his clinical file, are outlined below. Each therapy goal pursued during this period is linked to the corresponding plan goal.
-
NDIS Plan Goal: Increase independence in daily living activities at home and in the community.
- Therapy Goal: Sam will complete an independent school dressing routine with verbal prompts only on 4 out of 5 mornings, including management of buttons, zippers, socks, and shoes.
-
NDIS Plan Goal: Increase participation and independence at school.
- Therapy Goal: Sam will produce legible handwriting on lined paper for 4 lines with consistent letter size and baseline.
- Therapy Goal: Sam will cut simple shapes (circles, squares, triangles) within 5mm of the outline on 3 out of 4 attempts.
- Therapy Goal: Sam will independently use sensory self-regulation strategies in the classroom. (Achieved during the previous reporting period.)
Specific NDIS plan goal wording from Sam's current plan was not available in the documentation provided. The goals listed above reflect the therapy goals recorded in Sam's clinical file and are framed in alignment with typical NDIS plan goal language for a participant of Sam's age and profile.
Service Delivery Summary
Sam has been receiving fortnightly occupational therapy sessions at Summit Allied Health during the current reporting period (October 2025 to March 2026), with approximately 18 sessions delivered. Sessions focused on sensory regulation strategies, fine motor skill development (handwriting and scissor skills), and activities of daily living (dressing independence). A sensory diet programme was implemented collaboratively with Sam's family and school, incorporating heavy work activities, a weighted lap pad, and an ergonomic pencil grip.
Services delivered under this plan are billed under the following NDIS support item codes:
- 15_001_0118_1_3 - Early Childhood Intervention Professional - Occupational Therapist (Improved Daily Living Skills) at $193.99 per hour
Functional Progress
Goal 1: Independent School Dressing Routine
Baseline: Sam required hand-over-hand assistance with buttons, zippers, socks, and shoes. He was unable to initiate the dressing sequence independently.
Current Progress: Sam is now largely independent with dressing. He manages large buttons independently (4/5 attempts), can initiate zippers with moderate assistance but pulls up independently once started, and puts on socks and shoes with verbal prompts only. Parent reports mornings are significantly easier. COPM dressing performance score improved from 2/10 to 6/10 (change +4, clinically significant). COPM dressing satisfaction improved from 2/10 to 7/10 (change +5, clinically significant). Progress estimated at 75%.
Goal 2: Legible Handwriting on Lined Paper for 4 Lines
Baseline: Inconsistent letter formation, excessive pencil pressure, inability to maintain line spacing. COPM handwriting performance score 3/10.
Current Progress: Letter size more consistent, Sam can maintain baseline on lined paper for 3-4 lines before fatiguing. Adopted ergonomic pencil grip (Stabilo) consistently. School reports improved desk participation. COPM handwriting performance improved from 3/10 to 6/10 (change +3, clinically significant). Progress estimated at 65%.
Goal 3: Scissor Skills - Cutting Simple Shapes
Baseline: Sam was able to cut straight lines only, with no ability to cut curves or shapes. BOT-2 Fine Motor Composite standard score 28 (2nd percentile, well below average).
Current Progress: Sam can now cut simple shapes (circles, squares) with some deviation from the outline. COPM scissor skills performance improved from 2/10 to 5/10 (change +3, clinically significant). BOT-2 Fine Motor Composite improved to standard score 32 (5th percentile, below average). Progress estimated at 55%.
Previously Achieved Goal: Independent Sensory Self-Regulation in the Classroom
Sam successfully achieved the goal of independent sensory self-regulation prior to and during this reporting period. He can now identify when feeling overwhelmed and independently requests breaks. The sensory diet programme is embedded at home and school.
Current Functional Status
Self-Care and Daily Living
Sam has made significant progress in dressing independence. He manages large buttons, socks, and shoes with verbal prompts only (previously requiring hand-over-hand assistance). Zippers require moderate assistance to initiate. Shoe laces remain an area for ongoing work. COPM mean performance score improved from 2.2/10 to 5.2/10 (change +3.0, clinically significant). COPM mean satisfaction score improved from 2.0/10 to 5.4/10 (change +3.4, clinically significant).
Fine Motor Skills and School Participation
Sam's handwriting has improved in letter consistency and baseline maintenance, and he is functional for classroom demands. Scissor skills have progressed from straight lines only to cutting simple shapes. BOT-2 Fine Motor Composite has improved from the 2nd to the 5th percentile.
Sensory Regulation
Sam demonstrates independent use of sensory self-regulation strategies. He can identify when he is feeling dysregulated and requests breaks without prompting. The sensory diet is well-embedded across home and school environments.
Recommendations
1. Continued Occupational Therapy Sessions - Fortnightly
It is recommended that Sam continue to receive fortnightly occupational therapy sessions to support ongoing progress toward handwriting endurance, scissor skills, shoe lace tying, and food variety goals.
Recommended hours: 26 hours per year.
- Support Item: 15_001_0118_1_3 - Early Childhood Intervention Professional - Occupational Therapist
- Funding Category: Improved Daily Living Skills
- Rate: $193.99 per hour
2. Assessment and Programme Planning
Recommended hours: 4 hours per year for assessment and programme planning activities.
3. School Visit for Year 3 Transition
A school visit is recommended to observe Sam's functional performance in the classroom environment and liaise with school staff regarding sensory strategies and fine motor accommodations.
Practitioner Declaration
I declare that the information contained in this report is true and correct to the best of my knowledge and has been prepared in accordance with my professional obligations as an occupational therapist.
All participant names, NDIS numbers, and clinical data are entirely fictional.
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