Child referral Please complete this form Reason for referral (tick all that apply)(Required) Dyspraxia / coordination difficulties Sensory assessment Handwriting difficulties Fine motor skills assessment Intervention / therapy programme Parent / school coaching Not sure – would like advice Main concerns (in your own words)Has the child seen an Occupational Therapist before?(Required) Yes No If yes, when/where?Name of Child(Required) First Last Date of Birth DD slash MM slash YYYY SchoolAny diagnosis? (if so, when and who by)Hearing issues? Yes No Wears glasses? Yes No Date of last eye test DD slash MM slash YYYY Early development (if remembered): Sat independentlyCrawledWalkedToliet trained Yes No Feeding / cutlery use Age appropriate Difficulties noted Current strengths and challenges (tick if you notice concerns)Motor & Coordination Clumsy / frequent falls Balance / hopping / jumping difficulties Finds PE or playground equipment tricky Fine Motor / Handwriting Struggles with pencil grip, letter formation or spacing Scissors, ruler, threading, dressing skills delayed Attention & Organisation Easily distracted / poor attention Difficulty getting organised Writing doesn’t match verbal reasoning Sensory & Emotional Overwhelmed or frustrated easily Difficulties managing emotions Sensitive to sensory input (noise, clothing, movement etc.) What are your goals and hopes for occupational therapy?Anything else you’d like us to know?Name of Referrer(Required) First Last Email(Required) Relationship to Child(Required)
