Request for Occupational Therapy Coaching Support
This coaching support is an opportunity for teachers to access their assigned AEA OT as a resource to provide problem solving for identified areas of concern in their classroom.  Strategies provided are intended to enhance ongoing instruction provided by the teacher.  Teachers or IEP teams may want to consider adding this information to an eligible student's IEP.  It is not an evaluation for special education services or ongoing monitoring of skill development.  Teachers may request follow up as needed.

Please complete this form and your GWAEA OT will contact you via email upon receipt.  Please include as much information regarding your concern(s) as possible.  Collaborate with your team and submit one request only.
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Email *
Occupational Therapist *
Select the OT that supports your district or school
Person requesting OT coaching
This request should be made by school personnel.
Person completing request *
Person(s):  First and last name please.  You may list more than one name here.
Email address *
Please enter only ONE PRIMARY contact email address!
Demographic Information
School *
District *
Teacher *
Teacher Email *
Grade *
Date of Request *
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/
DD
/
YYYY
General classroom concern and/or student name *
If applicable
Student classification
If applicable
Clear selection
Area of Concern
Check all areas of functional school concerns that apply
Provide specific examples regarding your area or areas of concern and how these concerns impact educational performance and participation. *
List any MTSS interventions, strategies attempted, and outcomes related to your area of concern prior to contacting the OT. *
These are general education interventions implemented and outcomes as well as the strategies to support the area of concern
What is the expected performance in the area of concern? *
Outcome you are hoping for as a result of this coaching: *
PLEASE SEND YOUR ASSIGNED OT ANY WORK SAMPLES OR PICTURES THAT MAY BE RELEVANT TO YOUR AREA OF CONCERN VIA EMAIL
A copy of your responses will be emailed to the address you provided.
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