State of California—Health and Human Services Agency Department of Health Care Services
CALIFORNIA CHILDREN’S SERVICES
MEDICAL THERAPY PROGRAM (MTP)
THERAPY ASSESSMENT PLAN
Name Birth date CCS number
The above child has been referred to the California Children’s Services (CCS) Medical Therapy Program (MTP) for a physical
therapy (PT) and/or an occupational therapy (OT) assessment for medically necessary therapy services. The following tests
that have been checked will be administrated to your child to allow the therapist(s) to develop a proposed therapy plan.
Please sign below and mail or deliver this form to:
County CCS Program
, CA
Clinical Observations: The therapist’s observations of the child during the evaluation.
Activities of Daily Living: Functional skills such as mobility, transfers, ambulation, gait, eating, dressing, bathing,
grooming, toileting, home skills, and use of adaptive equipment.
Mobility: Manner in which the child moves about his/her environment, including gait analysis.
Range of Motion: Standardized testing of passive and active joint range.
Sensory: Response to position in space, object identification, two-point and tactile discrimination.
Fine/Gross Motor Skills: Motor maturity through age appropriate responses.
Reflexes: Postural responses, balance and equilibrium reactions.
Postural Alignment: Posture as it relates to the skeletal system and functional abilities.
Oral Motor Skills: Examination of the oral cavity, oral/facial reflexes, and assessment of ability to chew and manage
solids and liquids.
Perception: Standardized testing of child’s ability to receive, interpret, and use sensory impressions.
Respiratory: Assessment of child’s breathing.
Manual Muscle Test: Standardized measurement of muscle strength as it relates to gravity and resistance.
Other specialized assessment based on child’s medical needs, such as:
Home evaluation
Classroom evaluation
Use of photos or videotapes as a pictorial record
Other (specify):
My signature below indicates my permission for my child to be evaluated in the above marked areas.
Parent/caregiver Date
Original—File in MTU Case Record Photocopy 1—Send to Parent/Caregiver Photocopy 2—Send to Local Educational Agency (LEA)
Special Education Local Plan Area (SELPA)
DHCS 4098 (09/07)
