Santa Rosa City Schools
Department of Special Services
Occupational Therapy Referral Checklist
This student may be considered for an OT evaluation. The information you provide is a very
important part of that process. If the student is currently able to access the curriculum, and if
appropriate and documented accommodations have not been tried for a reasonable period of
time, an OT evaluation is not recommended.
A copy of any accommodations that have been recommended and used with the student must
be submitted with this checklist, before further consideration. Please, attach SELPA form 26b
or SELPA 5a from the appropriate IEP, if one has already been completed for a student!!
Page 3 must be completed before the student will be considered for an evaluation, if other
documented accommodations do not exist in any form. It is important to note if the
accommodation was helpful for curriculum access or not.
An OT observation may be performed before an evaluation when appropriate,
upon review of this completed packet.
This information is intended to support the decision-making process, in deciding, when an OT evaluation
may be appropriate to help a student meet their IEP goals:
When an OT Evaluation is Not Recommended
1. Problem does not interfere with student’s ability to participate in their educational program.
2. The unique expertise of OT is not required to meet the student’s identified need.
3. Other educational personnel are able to assist the student in areas of concern and do not require the
expertise of an OT.
4. Problem is not caused by limitations in OT performance domains (ex. fine motor/utilizing educational
materials/sensory processing/ ADLs related to school), that impede access to curriculum.
5. Potential for change is not likely or performance remains unchanged despite multiple efforts by
teaching staff or previous therapists to remediate the concerns, or to assist the student in compensatory
techniques.
6. Goals or outcomes requiring OT have been met and no additional goals are appropriate.
7. Problem ceases to be educationally relevant.
8. Therapy is contraindicated due to medical, psychological or social complications.
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OT Referral Checklist (Continued)
Page 2
Why are you requesting that this student be evaluated by an occupational therapist? Please be
complete and accurate. Attach additional pages including grade level performance in the areas
of reading, math, spelling and writing. Also, include examples of handwriting/drawing
samples.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Referral Information:
Person Making Request: ____________________________Position:____________________
Signature: ______________________________Date request submitted:________________
Principal: ___________________________________
Principal’s Signature: _____________________________
Comments: ________________________________________________________
Student Information:
Name: _____________________________Birth Date: _____ Gender: Male__ Female__
Grade: _____ School: ________________________
General Education Teacher: __________________________Phone:______________
Special Education Teacher: ___________________________Phone:______________
Language of Home: _____________Student’s Preferred Language:__ _____________
1. Parent/ Guardian Information:
Occupation: _________________ _______
Name: _____________________________ _____ Relation: ______________________
Street: _____________________________ ___ __ Home Phone: _________________
City, State, Zip: _______________________________ Work Phone: ________________
2. Parent/ Guardian Information:
Occupation: _____________________
Name: _____________________________ ______Relation: ________________________
Street: _____________________________________ Home phone: ____________________
City, State, Zip: _______________________________ Work Phone: ___________________
Teacher Information Checklist
This checklist must be completed and turned into the Special Services Department before an
OT observation or evaluation will be initiated unless, other accommodation pages from an
IEP have been provided with the referral packet, as stated on the first page. Please add when
the accommodations were started and who was implementing and documenting the outcomes.
Start date: ____________Provided in: SDC classroom ____Resource room_____ Gen ed _____
Teacher Information Checklist
Page 3
After checking the appropriate accommodations, please place a plus sign
(helpful), or minus sign (did not help) next it, in order, to indicate if this was a
successful strategy for the student.
Related to Support
___Check for understanding
___Instructions/directions repeated
___Present one task at a time
___Preferential seating__________
___Supervision during unstructured time
___ Cues/prompts/reminders of rules/procedures
___ Offer choices
___Note taking assistance/notes provided
___Use of a scribe/word processing
___Peer tutor/staff assistance:_______________
___Picture schedule
___Other:_______________________
___Prior or current Behavior Support Plan
___Home/school communication system
___Other:_________________________
________________________________
___Break tasks into smaller units of work
Related to Writing Skills
___Pencil holder/grips
___Large primary pencils/weighted pencil
Response to Materials/Instruction
___Reduced/shortened assignments/tests
___Extended time -class assignments/tests
___ Use of notes for tests/assignments
___Open book for tests/assignments
___Spelling errors will not impact grade
when editing assistance is unavailable
___Use of a calculator
___Proof-reader and redo assignment
___ Written mechanics not graded
___Graphic organizer
___Site word bank
___Enlarged text
___Books on tape
Settings
___Access to study carrel
___Free from visual distractions
___Quiet environment
___Small group environment
Related to Sensory Processing
___ Providing breaks/ break cards
___Time out space provided in class
___Adapted paper (highlighted lines)
___ Slant board
___Light sandpaper under writing surface
___Work at easel
___Dry erase board
___Rubber stamps-letters/numbers
___Word processor
___Avoid messy task if sensitive to textures
___Noise cancelling headphones
___Movement breaks over school day
___Heavy work jobs (carry, push, pull, lifting)
___Oral fidget for mouth/crunchy snacks
___Air pillow for chair
___Sensory choice list on desk
___Other:__________________________
_________________________________
___Other:___________________________
___________________________________
Signed by staff who observed the student using the accommodations listed above:
Teacher: ___________________________________
Date: ___________________
OT Referral Checklist
Page 4
Please complete the following list in order to help determine the most appropriate course of
action: OT observation/evaluation for the student, at this time.
Please check the following items that apply by frequency of occurrence, as observed:
Frequently: F
Sometimes: S
Unknown: U
Never: N
Please add, any relevant information in the Other area. More information is better. Thank you!
Fine Motor
Unable to complete written worksheets in class
___
Poor desk posture (slumps, leans on arms, head to close to work)
___
Poor pencil grasp- may be very loose or very tight (please circle)
___
Tight pencil grasp, fatigues quickly when writing
___
Changes grasp on pencil frequently
___
Pencil lines are wobbly, too faint, or too dark (please circle)
___
Writes very slowly or very quickly (please circle)
___
Difficulty using both hands to cut or manipulate materials
___
Does not cross midline of body (shifts body or switches hands)
___
Difficulty with dressing, buttons, zippers, or snaps
___
Other: ____________________________________________________________
____________________________________________________________________________
Visual Perceptual/Visual Processing
Difficulty copying designs, letters or numbers
___
Difficulty in organizing letters/numbers on page
___
Reversals of words, letters, or numbers after first grade
___
Uses uppercase letters within words/case confusion
___
Difficulty copying off chalkboard
___
Cannot attend to a writing/drawing task for an extended time
___
Writes over letters/ poor word spacing/ writes in middle of page (please circle) ___
Misses written directions more than other students
___
Poor line alignment, letter sizing/spacing and word spacing when writing
___
Difficulty editing written work for corrections
___
Difficulty finding place on worksheets or assignments
___
Leaves items blank on busy worksheet even when he/she knows answer
___
Other: _______________________________________________________________
______________________________________________________________________
Tactile (Touch) Processing
Seems overly sensitive to being touched, pulls away from light touch
Tends to wear only certain type of clothing or fabrics
Has difficulty with keeping hands to self, will poke or push other children
___
___
___
OT Referral Checklist
Page 5
Tactile (Touch) Processing
Touches things constantly, seeks tactile input frequently
___
Avoids putting hands in messy substances
___
Has difficulty with controlling interactions in group games, when peers are close ___
Other: _______________________________________________________________
_____________________________________________________________________
Auditory Processing
Has difficulty understanding or paying attention to what is being said
___
Misses oral directions more than other students
___
Easily distracted by sounds
___
Sensitive to noise/covers ears (bells, loud sounds)
___
Has difficulty following two-three step oral directions
___
Other: _______________________________________________________________
_____________________________________________________________________
Oral Motor/Processing
Difficulty in chewing, swallowing, or drools (circle)
___
Chews on clothing/objects or fingers in mouth
___
Sensitive/avoids certain food textures/limited diet
___
Other: ________________________________________________________________
______________________________________________________________________
Classroom Behavior
Restless (squirmy in chair or on floor)
___
Gets up and moves around more than other students
___
Attention span considerably shorter than other students
___
Withdraws from activities/intentionally leaves active environments or situations
___
Has difficulty tolerating changes in routines, plans and expectations
___
Withdraws when there are changes in the environment or routine
___
Is bothered by rules being broken
___
Other: ______________________________________________________________________
____________________________________________________________________________
Signed: ____________________________________Case/Program Manager for Spec Services
Date when all required referral information complete: ________________ ________
Thank you very much for taking the time to complete this information and returning it to the
Special Services Department in a timely manner.