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Occupational Therapy Referral Form
Occupational Therapy Referral Form
Child's Details
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Full Name
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Is your child currently receiving other OT Services:-
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(e.g. Ed Qld, Private Practice, Helping Children with Autism Package)
Referral Details
Reason for Referral/Current Concerns
Diagnosis/ Presenting Condition
Any other relevant information
Please attach any relevant reports/ documentation)
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What are your child’s top three strengths?
What are your current priorities/concerns including those raised by school or others
(e.g. Speech Pathologist)
Please comment on your child’s skills (strengths and difficulties) in the following areas
Fine Motor Skills
Using their hands and fingers: e.g. drawing, cutting, writing, doing up zips/buttons
Gross Motor Skills
Running, jumping, skipping, climbing
Speech and Language
Talking, understanding instructions, listening
Play and Social Skills
With adults and with other children; at school and/or at home
Self Help Skills
Dressing, toileting, brushing teeth
Behaviour and Concentration
At home and in the classroom
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