Enabling inclusive participation is an overarching goal of Occupational Therapy services in the school setting; however, evidence is scarce on practices addressing it. This study conducts an in-depth examination of actual Occupational Therapy practices with students with physical disabilities in mainstream schools and explores possible directions toward facilitation of successful participation. Eight Occupational Therapists representing different practice settings and regions of a large Canadian province were recruited, each providing two distinct charts of students with physical disabilities integrated in regular classrooms. Data extracted from charts was analyzed and coded based on the International Classification of Function, Disability, and Health. Chart-stimulated recall interviews were conducted with each therapist and analyzed thematically. Services focused predominantly on academic rather than social activities. Two overarching themes emerged describing the clinical reality including resources (e.g. time and teams) and the impact of occupational therapy (e.g. service delivery and promotion of the profession). Subthemes suggest expansion of practice scope and diversification of service delivery modalities as promising directions. Facilitation of fuller inclusion and participation of students with physical disabilities in the school setting by Occupational Therapy services may require additional resources including knowledge translation initiatives relating to collaboration and facilitation of social participation in schools.