Occupational Therapy Referral Form

Full Name

Date of Birth

Home Address

Current School/Day Care

Full Name

Relationship to Child

Phone

Mobile

Is your child currently receiving other OT Services:- *

Yes

(e.g. Ed Qld, Private Practice, Helping Children with Autism Package)

Reason for Referral/Current Concerns

Diagnosis/ Presenting Condition

Any other relevant information Please attach any relevant reports/ documentation)

Upload Reports/Documentation Files Upload File

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)

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