Physician Referral for School-Based Occupational/Physical Therapy Services
Information will assist with educational planning and is not intended to replace therapy you may prescribe for medical
purposes. A physician’s signature is required before the initiation of therapy services.
Student Name: ______________________________________________
Date of Birth: _________________________________________
IEP/504 Plan Date: ________________________________________
Home District: ________________________________________
☐ Occupational Therapy Required
Therapist: __________________________________________________
☐ Physical Therapy Required
Therapist: __________________________________________________
☐ Sensory Processing
☐ Gross Motor
☐ Fine Motor
☐ Visual Motor
Services: ☐ Direct ☐ Consult
☐
☐
☐
☐
Perceptual Motor Skills
Assistive Technology
Adaptive Equipment
Gait/Pre-gait
☐ Position/Transfers
☐ Independent Living Skills
☐ Splinting
☐ Other: ____________________________________
Number of Minutes: __________________
Program site: ______________________
Parent/Guardian Portion
This referral should be sent to the following physician for signature:
Name: ____________________________________________________________________________
Phone: _______________________________________
Address: ______________________________________________________________________________________________________________________________
☐ I give permission for Johnsburg School District 12 personnel and the above-referenced physician to exchange school and medical information.
Parent/Guardian Signature: ___________________________________________________________________
Date: ___________________________
Physician Portion
Illinois State Law requires that the physician provide an original signature. This referral will be used for the therapies
recommended above unless contraindicated.
Diagnosis/Description of Disability: _________________________________________________________________________________________________
Primary Diagnosis Code (if assigned): __________________________
Secondary Diagnosis Code (if assigned): _____________________
Precautions/Restrictions:
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Significant Medical Information – Including relevant surgical summary:
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Physician Signature: __________________________________________________________________
Return to:
Date: ______________________________________
Rich Schisler, Director of Student Services
Johnsburg School District 12; 2222 W. Church Street; Johnsburg, Illinois 60051