Vision Therapy Resources
This section includes forms
frequently used by our therapists. This covers everything from VT session notes, Homework report sheets,
notifications when Homework is not being done, when the quality of Homework isn't there, as well as
documentation for the Progress Evaluations. This section also includes our Final Success Story Form to be filled
out upon Graduation from our program.
This sheet is a sample of the forms we use
to catalog the notes from each individual therapy session. When a patient starts therapy, the Scheduling Manager
will prepare the file and place the appropriate number of these sheets in the patient file. Each sheet holds the
notes for three therapy sessions.
2. Home Therapy Report
We give this sheet to each patient after
each session to catalog homework completed and feedback on each procedure.
3. Homework Notification
These forms are given to the patient when
they are not completing homework up to the expected standards. They also alerts the patient of a possible
extension of the program if the lack of homework continues. We have rarely had to issue additional warning
after the first level, but there are three levels of warnings with the third warning requiring involuntary
expulsion from the program. We have not yet had to use this option
since the first warning is usually very effective.
4. Quality Homework
This is an additional notification that we
use when a patient is not completing quality homework at home. Examples include: poor attitude/lack of
motivation, lack of parental supervision, lack of feedback on the Homework Report sheet, number of days EACH
procedure is completed (some patients we see pick and choose what they complete), or trying to do homework
multiple times per day to make up for missed days. The areas of concern are checked off and reviewed with the
patient/parent. All parties sign the form and each receives a copy for future reference.
This is a very basic sheet we keep in each
patient file to control inventory flow in and out of the office.
The first time we check out a piece of equipment we review the return policies and the cost of breaking or
losing each item listed. A parent needs to sign the form acknowledging that they understand the policies. This
is also reviewed by the therapist upon graduation or exit to ensure the return of our
8. Reminder to Schedule Progress Evaluation
This is a simple reminder sheet to schedule
a PE. We do not schedule the evaluation until the therapist feels the patient is ready for the testing that will
be conducted by the doctor at that time.
9. Progress Evaluation
This form is filled out by the therapist
prior to the Progress Evaluation. They will information on patient performance at the first therapy session and
the most recent therapy session for comparison in several areas. This sheet gives the doctor a "Report Card"
effect during the PE to show what the therapist is seeing in the therapy room. It also gives the doctor a good
feel for the parent's attitude towards the program so far and what topics to expect them to bring up.
10. Final Program
Evaluation and Success Story
This form has multiple uses, not limited
to: overall impressions of their experience, willingness to be a future patient reference or participate in a
news article, their personalized success story (which we type up and put in the Success Story books in the
lobby), as well as the improvement in their symptoms. We use this form as well as the doctor’s final PE findings
to formulate our success rate that we give to prospective patients. Any feedback for the therapist (positive or
negative) is copied for their personnel file for reference during yearly performance reviews.