3LPlace Assessment Tool
Created by Elana Himmelfarb and June Peoples Mallon of 3LPlace with thanks to Dr. Gary Bedell of Tufts University Department of Occupational Therapy for his review and input.
Use this tool to assess an individual’s current state and to track progress over time.
Assess the first two categories (Regulation and Participation) prior to all work.
If Regulation or Participation are challenged enough to be an impediment, consider delaying work until a time where it is more possible or consider providing accommodations as required.
Assess the other seven categories on a regular basis, either monthly or at a minimum quarterly.
Staff should be instructed in its use and should have ongoing supervision as required so that there can be consistency in how the assessment is applied program-wide.
You can print out this form using the icon to the right and slightly above the page name.
As always, your input and feedback on this form are welcome. You can become a registered user of the 3LPlace wiki here.
Survey and Scale
Name of participant
Staff administering
Date of assessment
Regulation (attention, anxiety, sensory and emotional)
1 - significant strength
2 - moderate strength
3- average
4 - moderate challenge
5 - significant challenge
Participation (reciprocity, engagement and level of interest)
1 - significant strength
2 - moderate strength
3- average
4 - moderate challenge
5 - significant challenge
Independence (level of facilitation required to initiate and complete task)
1 - significant strength
2 - moderate strength
3- average
4 - moderate challenge
5 - significant challenge
Sequencing (correctly ordering items, events or concepts according to time and progression)
1 - significant strength
2 - moderate strength
3- average
4 - moderate challenge
5 - significant challenge
Critical Thinking (comprehension, compare/contrast, cause/effect, analysis, drawing conclusions, problem-solving, decision-making)
1 - significant strength
2 - moderate strength
3- average
4 - moderate challenge
5 - significant challenge
Executive Function (planning, previewing, task execution, organization, self-monitoring, strategic thinking, time-management)
1 - significant strength
2 - moderate strength
3- average
4 - moderate challenge
5 - significant challenge
Motor Planning (ideation, organization and execution of tasks requiring movement, body awareness and coordination; level of automaticity and flow with coordination and movement)
1 - significant strength
2 - moderate strength
3- average
4 - moderate challenge
5 - significant challenge
Receptive Language (language input of concrete and abstract verbal information: understanding vocabulary, verbal instructions and meaning while listening and/or reading)
1 - significant strength
2 - moderate strength
3- average
4 - moderate challenge
5 - significant challenge
Expressive Language (language output surrounding concrete and abstract information: vocabulary/word choice, communicating meaning and reflecting understanding through speaking, movement and writing)
1 - significant strength
2 - moderate strength
3- average
4 - moderate challenge
5 - significant challenge
© This research and tracking tool is owned and copyrighted by 3LPlace, Inc. Reproduction is permitted for use with individuals or in academic settings. It may not be reproduced for sale. Thank you!