OT/PT REFERRAL FORM
TEACHER NAME: _____________________SCHOOL__________________________
STUDENT NAME: ___________________________________AGE________________
Postural Stability:
Student exhibits difficulty in the following:
_____Unusual standing or running posture _____Sits in required floor posture
_____Leaning on desk/slouching in desk
_____Stays seated (as expected for age)
_____Eyes close to paper
_____High/low activity level
Description of above concerns:_______________________________________________
________________________________________________________________________
What strategies have been tried?
_____seat cushion/wedge
_____consult for desk fit
_____back rest for floor time
_____vision screening/exam
Response to intervention:___________________________________________________
_______________________________________________________________________
Recreational/Functional Mobility:
Student exhibits difficulty in the following:
_____Hallway mobility
_____Participation in playground activities
_____Maintaining self in line
_____Participation in PE activities
_____Transitions within classroom
_____Endurance for a full school day
Description of above concerns:_______________________________________________
________________________________________________________________________
What strategies have been tried?
_____Change line position (first/middle/last) _____Peer buddy on playground/in PE
_____Increase pathway width
_____Rest/motor activity breaks
Response to intervention:___________________________________________________
_______________________________________________________________________
Self Care Skills:
Student exhibits difficulty in the following:
_____Fasteners-zipper/buttons/shoe tying _____Coat/gloves/PE shoes
_____Toileting
_____Lunch room/self feeding/opening milk
Description of above concerns:_______________________________________________
________________________________________________________________________
What strategies have been tried?
_____Picture sequence of tasks
_____1:1 physical modeling
_____Alternative clothing fasteners
Response to intervention:___________________________________________________
_______________________________________________________________________
Classroom Tool Use:
Student exhibits difficulty in the following:
_____Staples/Tape/Ruler/Folders
_____Hand dominance (left/right)
_____Tremors/stiffness of hands
_____Obtaining/storing materials
_____Scissors (choppy, coordination)
_____Coloring within boundaries
Description of above concerns:_______________________________________________
________________________________________________________________________
What strategies have been tried?
_____Adapted tools
_____1:1 instruction/practice
_____Alternative storage
_____Increase visual contrast
Response to intervention:___________________________________________________
_______________________________________________________________________
Handwriting(enclose sample):
Student exhibits difficulty in the following:
_____Organization of work on page
_____Writing utensil grasp
_____Letter proportion/formation/placement _____Pencil pressure
_____Quality of written work
_____Time to complete written work
_____Copying from book/board
_____Stabilizing paper
Description of above concerns:_______________________________________________
________________________________________________________________________
What strategies have been tried?
_____Alternative writing paper
_____Alternative writing utensil/grips
_____Visual model on desk/board
_____Slanted writing surface
_____1:1 instruction/practice
_____Decrease visual clutter
_____Other:_____________________________________________________________
Response to intervention:___________________________________________________
_______________________________________________________________________