Occupational/Physical Therapy Referral Form

Barton County Special Services
2535 Lakin
Great Bend, Kansas 67530
(620) 793-1550 ~ Fax (620) 793-1551
Occupational/Physical Therapy Screening Form
Date of Referral:
Student’s Name:
School Contact Person/Teacher:
Reason for Referral:
Referral Source:
Parent Name:
Hm Phone#:
Wk Phone#:
Currently receiving other special education services.
Please list:
This form is to be used if you have any questions regarding the appropriateness of a referral for occupational
and/or physical therapy services. Please check the statements, which best describe your concerns about the
student’s performance skills.
If concerns are primarily gross motor contact Sandy Showalter, PT, if concerns are primarily fine motor
contact Coleen Moore, OTR at (620) 793-1550.
Gross-Motor Skills
Are the child’s skills commensurate with peer performance?
Appears weak, tires easily
Clumsy and bumps/trips easily
Arms, hands, legs or feet appear deformed or abnormal
Difficulty initiating movements or getting started in activity
Difficulty working body parts together (i.e. hopping, skipping, jumping jacks)
Asymmetry (both sides not equal to each other, appear uneven)
Poor posture, sitting and/or standing
Difficulty walking (hips and knees are always bent or walks on toes)
Confuses right and left
Cannot rise from floor without help, wants to hold onto person or object
Sometimes makes no attempt to catch self when falling
Reluctant or unable to use playground equipment or participate in gym class
Fine-Motor Skills:
Are the child’s skills commensurate with peer performance?
Poor sitting posture (slumps in chair, leans to one side, fidgets)
Poor pencil/crayon grasp
Tremors, poor dexterity (difficulty with clothing, small object manipulation)
Difficulty drawing, tracing, coloring, cutting
Pencil pressure is too light or too heavy (breaks tip of pencil)
Rarely completes written tasks in allotted time frame
Hand dominance is not established, not skillful with either hand
Seldom reaches to opposite side during writing/table activities (turns body
consistently or switches hands at middle of body)
Fine-motor screening must include samples of typical handwriting/classroom work
Visual-Perceptual Skills:
Are the child’s skills commensurate with peer performance?
Unable to recognize all letters of the alphabet
Unable to distinguish between upper and lower case letters
Difficulty discriminating between colors, size and shapes
Poor eye-hand coordination (tracing, hitting a ball)
Consistent letter or number reversals after 1st Grade
Difficulty discriminating relevant from irrelevant visual stimuli
Poor eye-tracking skills (moves head to follow an object, poor eye contact with object)
Becomes easily frustrated
Leaves seat often
Apt to be impulsive, accident-prone
Refuses to engage in tasks
Minimal eye-contact during activity
Restless, short attention span (note how long)
Inconsistent responses to familiar tasks