SRCS 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.
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.
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 Response to Materials/Instruction
___Check for understanding ___Reduced/shortened assignments/tests
___Instructions/directions repeated ___Extended time -class assignments/tests
___Present one task at a time ___ Use of notes for tests/assignments
___Preferential seating______Open book for tests/assignments
___Supervision during unstructured time ___Spelling errors will not impact grade
___ Cues/prompts/reminders of rules/procedures when editing assistance is unavailable
___ Offer choices ___Use of a calculator
___Note taking assistance/notes provided ___Proof-reader and redo assignment
___Use of a scribe/word processing ___ Written mechanics not graded
___Peer tutor/staff assistance:______Graphic organizer
___Picture schedule ___Site word bank
___Other:______Enlarged text
___Prior or current Behavior Support Plan ___Books on tape
___Home/school communication system Settings
___Other:______Access to study carrel ______Free from visual distractions
___Break tasks into smaller units of work ___Quiet environment
___Small group environment
Related to Writing Skills Related to Sensory Processing
___Pencil holder/grips ___ Providing breaks/ break cards
___Large primary pencils/weighted pencil ___Time out space provided in class
___Adapted paper (highlighted lines) ___Avoid messy task if sensitive to textures
___ Slant board ___Noise cancelling headphones
___Light sandpaper under writing surface ___Movement breaks over school day
___Work at easel ___Heavy work jobs (carry, push, pull, lifting)
___Dry erase board ___Oral fidget for mouth/crunchy snacks
___Rubber stamps-letters/numbers ___Air pillow for chair
___Word processor ___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.