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Click on the categories below to view sample forms.
You must download or copy the forms to edit.

(These forms & resources have been shared by your fellow colleagues across the state!)

  • PT Satisfaction Survey () () – provided by Durham Public Schools
  • PT Pink Sheet | Durham () () – provided by Durham Public Schools
  • PT Parent Contact Form () ()Ìý – provided by Durham Public Schools
  • PT MD Contact Form () () – provided by Durham Public Schools
  • PT Orthotic Referral () ()Ìý – provided by Durham Public Schools
  • PT Intro Letter () ()– provided by Durham Public Schools
  • PT Consult () ()– provided by Durham Public Schools
  • PT Pamphlet () () – provided by Durham Public Schools
  • Parent Questionnaire () () – provided by Durham Public Schools

APTA Pediatric Resource-

  • Student Equipment Log () () – provided by Winston-Salem/Forsyth County Schools
  • LMN Log () () – provided by Winston-Salem/Forsyth County Schools
  • Protective Device Form () () – provided by Durham Public Schools
  • PT Loan Agreement () () – provided by Durham Public Schools
  • PT Waiver of Liability () () – provided by Durham Public Schools
  • Student Equipment Log () () – Winston-Salem/Forsyth County Schools
  • Section 504 Individualized Eligibility Report provided by Weldon City
  • Bruininks Evaluation () () – provided by Durham Public Schools
  • Re-evaluation () () – Winston-Salem/Forsyth County Schools
  • Generic OT Evaluation () ()
  • Peabody 2 Evaluation () () – provided by Durham Public Schools
  • Peabody Form () () – provided by Durham Public Schools
  • Physical Therapy Evaluation Form () ()
  • Preschool Functional Inventory () () – Maryland
  • PT-Gross Motor Checklist () () – provided by NYC
  • PT Functional Evaluation – Nonambulatory () () – provided by Cumberland County Schools
  • PT Functional Evaluation () () – provided by Cumberland County Schools
  • PT Functional Evaluation () () – provided by Durham Public Schools
  • PT School Function Evaluation – Middle & HS () () – provided by NYC
  • PT School Function Evaluation Appendices Middle and HS () () – provided by NYC
  • PT School Function Evaluation – Pre-K & Elementary () () – provided by NYC
  • PT School Function Evaluation Appendices – Pre-K and Elementary () () – provided by NYC
  • SFA Eval SFA () () – provided by Durham Public Schools
  • Summary Score FormÌý() () – provided by Durham Public Schools
  • Student Functional Inventory () () – Maryland
  • Tests & Measures Cheat Sheetprovided by NYC
  • An Example of language for a contingency plan – “Physical therapist will provide guidance and instruction to facilitate progress of foundational skills necessary for functional mobility goal attainment during direct virtual physical therapy services.” – Newton Conover City Schools
  • Documentation of Body Mech Training () () – provided by CMS
  • Grid Game, Submitted by Rockingham Co Schools
  • – permission was not granted for the original videos to be posted publicly, however this list will give you ideas of videos you can create on your own. – Pitt County Schools
  • I Am Here: A Booklet About Mindfulness, by Eleanor Cole
  • School Start up Checklist () () – provided by Durham Public Schools
  • Goal Achievement Analysis () () – provided by New Hanover County Schools
  • Gross Motor Skills in Sensory Diet () – provided by New Hanover County Schools
  • PT Discharge from Services () () – provided by Durham Public Schools
  • PT Do the Math () ()
  • PT Peer Review Checklist Sample () () – provided by Durham Public Schools
  • PT Service Levels () () – Winston-Salem/Forsyth County SchoolsÌý
  • Documentation of Wheelchair Management and Mob Training () () – provided by CMS
  • Evacuation Plan for Physical Therapy () () – provided by CMS
  • Functional Mobility in Education Environment () () – provided by CMS
  • General Safety Assessment () ()
  • PT Training Form () () – provided by Durham Public Schools
  • School Safety Drills for Physical Disabilities () () – provided by CMS
  • PT Continuing Education Record () () – provided by Durham Public Schools
  • PT Monthly Planner () () – provided by Durham Public Schools
  • PT Schedule – A () () – provided by Durham Public Schools
  • PT Schedule – B () () – provided by Durham Public Schools
  • PT To-Do List () () – provided by Durham Public Schools
  • PT Weekly Planner () () – provided by Durham Public Schools
  • Generic Plan of Care ()
  • PT POC Form ()
  • SBPT Plan of Care ()
  • School PT Plan of Care () ()
  • PT Department – Plan of Care (pdf) (doc) –Ìýprovided by ABSS
  • Plan of Care Template () () –Ìýprovided by Cleveland County Schools
  • Sample School-Based Occupational Therapy Plan of Care () ()
  • Sample School-Based Occupational Therapy Intervention Plan () ()
  • Sample School-based Psychological/Counseling Plan of Care () ()
  • Plan for Skilled Intervention/Plan of Care SLP () ()
  • Bench Sitting on Floor () ()
  • Communication Log () ()
  • Long Sitting () ()
  • I.E.P. Team Goals and Objectives () ()
  • Positioning for Education Adaptive Equipment Handout () ()
  • Positioning for Education Desk and Chair Handout () ()
  • Positioning for Education Floor Time Handout () () – provided by CMS
  • Positioning for Education Wheelchair Handout () ()
  • Procedure Log Sheet and Comments () ()
  • Prone on Wedge PF () () – provided by Durham Public Schools
  • Sidelyer Positioning Data Form () () – provided by Durham Public Schools
  • Stander Positioning Data Form () () – provided by Durham Public Schools
  • Tumbleforms Seat Positioning Data Form () () – provided by Durham Public Schools
  • PT Support Descripton () () (Wake)
  • Related Service Support Description Note to Parent () () (Union)
  • Documentation of Restroom Training () () – provided by CMS
  • Restroom Data Collection () () – provided by CMS
  • Restroom FAQ () () – provided by CMS
  • Restroom Procedure Form () () – provided by CMS
  • Restroom Strategies and Adaptive Equipment () () – provided by CMS
  • Sample PT contract (NHC) () ()
  • Sample OTPRN Contract () ()
  • Sample PT Contract (pdf) ()
  • SLP Sample Contract () ()
  • Exceptional Children’s Program () () – provided by Durham Public Schools
  • Gross Motor Skill Level () () – provided by New Hanover County Schools
  • Motor Screen (pdf)provided by Randolph County School System
  • Motor Screen 2.5 to 3 yr () () – provided by Craven County Schools
  • Motor Screen 3 to 3.5 yr () () – provided by Craven County Schools
  • Motor Screen 3.5 to 4 yr () () – provided by Craven County Schools
  • Motor Screen 4 to 5 yr () () – provided by Craven County Schools
  • Motor Screen for Preschoolers (pdf)provided by Randolph County School System
  • Motor Screening () () – provided by Durham Public Schools
  • Motor Screening Form () () – provided by Craven County Schools
  • Motor Screening Tool (pdf)provided by Buncombe County Schools
  • OT and PT in Public Education () ()
  • OT-PT Referral () () – provided by Durham Public Schools
  • OT-PT Referral Form () ()
  • PT – Gross Motor Pre-Referral Strategies () ()
  • PT Referral Checklist () () – provided by Durham Public Schools
  • PT Screening () () – provided by Durham Public Schools
  • PT Teacher Screening () () – provided by NYC
  • School Function Motor Screen (pdf)provided by Randolph County School System
  • Daily Progress Note Form Filled Sample (NYC) () ()
  • Student Service Information/Attendance Log () () – provided by Durham Public Schools
  • Daily Progress Notes () () – provided by Durham Public Schools
  • Progress Note () () – provided by Durham Public Schools
  • Sample Goal Data Collection () ()
  • PT Attendance Log () () – provided by Durham Public Schools
  • PT Record () () – Winston-Salem/Forsyth County Schools
  • PT Therapeutic Log () () – provided by Durham Public Schools
  • PT Student Needs School Transition Form () () – provided by Durham Public Schools
  • Sample Transition Letter CP () () – provided by CMS
  • Sample Transition Letter Spina Bifida () () – provided by CMS
  • Student Transition Checklist () () – provided by CMS
  • Student Transition Info for PT () () – provided by CMS
  • Telehealth Transition Checklist (CMS)Ìý
  • Procedures for Bus Loading Walker-Crutches () () – provided by CMS
  • Procedures for Bus Loading Wheelchair () () – provided by CMS
  • Procedures for Occupant Restraint () () – provided by CMS
  • Procedures for Using Integrated Child Restraints on the Bus () () – provided by CMS
  • Procedures for Using Safety Vests on the Bus () () – provided by CMS
  • Procedures for Using STAR on the Bus () () – provided by CMS
  • Procedures for Wheelchair Tie down straps () () – provided by CMS
  • PT Transportation Form () () – provided by Durham Public Schools
  • PT Transportation Safety List () () – provided by Durham Public Schools
  • () – provided by Durham Public Schools
  • Student Profile Transportation Considerations () () – provided by CMS