Occupational Therapy Referral Form

This form is confidential and will only be used by the intended recipient for information purposes.

It is possible for you to save this form in order to complete it at a later stage. To do so please provide your email address at the end of the form before clicking the save button.

Slindon College's Occupational Therapy Team are members of Royal College of Occupational Therapists and registered with the Health and Care Professions Council

Pupil's details


First name
Surname
DOB

Home address GP name and address Please provide school year group at Slindon College

Is an EHCP in place?YesNo

Parent/carer details


Full name (s)
Mobile number
Home phone number

Who has parental responsibility?As aboveOther

If other, please provide details

Has your child been seen by an occupational therapist (OT) before?YesNo

If no, please move to the next page. If yes, continue below.

When was your child last seen by an OT? (Approximate month and year is adequate.)

Are you happy for us to contact your child’s previous OT?YesNo

Please provide their contact details below and please upload or email over copies of recent OT reports

If other please specify Please complete for each service currently working with your child

	Name of service provider	Contact details	Date of support	Additional information

Developmental History

Birth history (please select one optionComplicatedNormalPremature

If premature, how early was your child born? Any significant medical history, separation from caregivers or trauma Diagnosis (including awaiting/being assessed for and date and by whom) Is your child currently taking any medication? Development milestones

	Age
Rolling
Sitting
Crawling
Walking
Talking (first words)

Communication (e.g any concerns regarding the child’s language development or use?) Fine motor skills (e.g are there any concerns regarding the child's tool use, handwriting, dressing skills, manipulation of small objects etc?) Gross motor skills (e.g are there any concerns regarding the child’s balance, coordination, sequencing of movements, do they tire quickly, appear clumsy etc?) Visual motor skills (e.g can they copy actions, can they copy drawings/words, can they find things in a room, any eye-hand coordination concerns etc?) Self-care and routines (e.g are there any concerns dressing/undressing self, toileting, feeding, sleeping, following routines etc?) Social skills (Are there concerns regarding making and maintaining friends, does the child prefer to play alone/with others, do they get along with their siblings etc?) Life skills (e.g do they undertake chores at home, simple meal prep, shopping, use public transport, have interview skills/exam techniques, organisational skills etc?) Regulation (e.g are there any concerns regarding calming down, overreactions to situations, difficulty focusing etc?)

Sensory

Touch (e.g do they dislike messy hands, not like certain textures, dislikes/likes people touching them etc?)

Smell (e.g doe they notice smells that others don’t, are they bothered by smells etc?)

Vision (e.g are they bothered by bright lights etc?)

Auditory (e.g do they dislike loud noises or busy environments, seek out music etc?)

Food (e.g do they have limited diet/dislike certain foods, do not like food touching, do not like eating in front of others etc?)

Movement (e.g are they often bumping into people or objects, have difficulty staying still, easily dizzy, poor balance, difficulty accessing stairs etc?)

Interoception: (e.g: can they recognise when they are hungry, thirsty, in pain, feeling hot/cold or need the toilet?)

Please provide details What are your child's strength and interests? What are your main concerns at the moment around your child’s daily occupations? What do you hope Occupational Therapy can achieve? What impact do you feel your concerns have on your child? What is the impact of these concerns from your child’s perspective? (i.e. their awareness of it, the impact on their life.) Any other information you would like us to be aware of?

Data Protection

When pupils are referred into the Occupational Therapy service we hold data about them to help us deliver the right support (e.g. information gathered from family members/professionals). This helps us track the effectiveness of intervention, and ensure high quality. The data is kept securely (in line with the school data policy), and would only be shared with those who need to know.

Parent/carer consent*I give consent for my child to partake in Occupational Therapy sessions, including any therapy assessments required. If intervention is implemented, I understand that progress cannot be guaranteed. I give consent for information to be shared with the appropriate agencies where it is in the best interest of my child.Please tick the box to confirm you, as the child’s caregiver, completed this form and that the information provided is accurate.

Please enter your name* Please enter your email address

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