Teacher:	School:

Grade Level/Subject:	Date:

U=Unsatisfactory	NI=Needs Improvement	P=Proficient	E=Excellent

Domain 1 – Planning and Preparation (circle domain rating)	U	NI	P	E
1a. Knowledge of Therapeutic Discipline and Law Pertaining to School System Practice
1b. Knowledge of Typical and Atypical Child and Adolescent Development
1c. Establishing Therapeutic Goals
1d. Designing Therapy Services With Appropriate Resources
1e. Developing a Plan to Evaluate Therapeutic Services
Domain 2 - Classroom Environment (circle domain rating)	U	NI	P	E
2a. Creating an Environment of Respect and Rapport
2b. Establishing a Therapeutic Environment of Learning, Participation, and Independence
2c. Managing Time, Procedures and Physical Space
2d. Managing Student Behavior
Domain 3 – Instruction (circle domain rating)	U	NI	P	E
3a. Communicating With and On the Behalf of Students
3b. Implementing and Adapting Therapy Services to Maximize Students’ Success
3c. Engaging Students in the Therapy Process
3d. Using Assessment/Evaluation to Guide Therapy
3e. Demonstrating Flexibility and Responsiveness
Domain 4 – Professional Responsibility: (circle domain rating)	U	NI	P	E
4a. Reflecting on Practice
4b. Maintaining Accurate Records
4c. Communicating with Families
4d. Growing Individually and Collectively as a Professional
4e. Showing Professionalism