Student Name: Date:
School:
Occupational Therapy Referral Checklist
Teacher/Grade:
Diagnosis: Current Support Services:
The following checklist has been designed to assist teachers and other school personnel in establishing appropriate Occupational Therapy referrals. It further helps to determine the most appropriate evaluation for the student. Please check only the items that interfere with school performance. Thank you.
Fine Motor Hand dominance right, left, mixed (circle one)
Difficulty drawing, coloring, copying ,cutting
Difficulty with dressing, coat, buttons, zippers, shoe tying
Difficulty opening food containers, packets
Poor pencil grasp
Pencil lines shaky, dark, light, breaks pencil lead
Written work is excessively slow and labored
Visual Motor
Difficulty coloring within the lines
Difficulty cutting lines, shapes, choppy snips
Unable to copy simple designs such as circle, square, triangle
Difficulty staying on the line when writing, changing size of letters, poor spacing
Difficulty with formation of letters
Visual Perceptual
Known visual problems? Wears glasses? Yes No (circle one)
Difficulty naming or matching colors, shapes, or sizes
Difficulty completing puzzles
Reversals in words or letters
Difficulty keeping place when reading
Difficulty copying from blackboard to desk, book to desk
Difficulty sequencing or recalling visual material
Difficulty locating objects in busy areas i.e. locker, desk, book bag

Sensory
Seeks movement: spinning, bouncing, jumping
Avoids big movements, swing, jumping
Overly sensitive to noise, fire drills, bells, cafeteria, playground
Seeks noise, inappropriate noise making
Difficulty sitting still, staying in seat
Seeks quiet, enclosed spaces
Avoids being touched
Avoids messy activities
Have modifications and/or strategies in this book been tried for at least 2 weeks? If so, which ones?
Have the students difficulties increased or decreased with the modifications and/or strategies? Please explain.
Additional Comments:
Completed by:
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