Occupational Therapy Referral Form Child’s name*NDIS NumberIf ApplicableDate of Birth* Date Format: MM slash DD slash YYYY Address Street Address City State Post Code School/Day care (if applicable)School Year LevelIf ApplicableTeacher / School ContactName of parent(s)/caregiver(s)Parents’/caregivers’ contact Phone:EmailReferral completed byRelationship to childReferrer’s contact details (if not parent/caregiver)Date of referral Date Format: MM slash DD slash YYYY Reason for referralPrevious therapyIf applicableDiagnosis/medical condition(s)If applicableWhat does your child enjoy?What does your child dislike?What do you feel are your child’s strengths?What do you feel are your child’s areas of difficulty?What would you and your child like to gain from therapy?Skills / DifficultiesDressing (including buttons, shoelaces, etc)IndependentNeeds some helpNeeds a lot of helpCommentsToiletingIndependentNeeds some helpNeeds a lot of helpCommentsGrooming (including brushing teeth/hair, etc)IndependentNeeds some helpNeeds a lot of helpCommentsFeeding ( including using cutlery if applicable)IndependentNeeds some helpNeeds a lot of helpCommentsShowering/bathingIndependentNeeds some helpNeeds a lot of helpCommentsSleepIndependentNeeds some helpNeeds a lot of helpCommentsPlease tick any areas of concern regarding your child’s fine motor skills: Holding pencils/crayons Forming letters/numbers Snipping with scissors Drawing simple pictures Doing up buttons/ zips Other ( please explain below) Further comments about fine motor skills:Please tick any areas of concern regarding your child’s gross motor skills: Running, skipping, hopping, jumping Clumsiness, awkwardness, falling often Throwing/catching Other ( please explain below) Further comments on your child’s gross motor skills:Please tick any areas of concern regarding your child’s social skills: Making/keeping friends Eye contact Personal space Appropriate topic of conversation Managing emotions Tantrums/meltdowns Other ( please explain below) Further comments on your child’s social skills:Please tick any areas of concern regarding your child’s sensory processing skills: Sensitivity to bright lights Sensitivity to loud noises Difficulty with certain textures e.g. food, clothing etc. Needing to fidget more than peers (i.e. touching/fiddling with objects) Needing to move more than peers Further comments on your child’s sensory processing skills:Please provide comments on your child’s overall behaviour:Other: This iframe contains the logic required to handle Ajax powered Gravity Forms.