Hays-Blanco Special Education Co-op

Request for Occupational Therapy/Physical Therapy

______Date Sent ______Date Received ______Date Due

Student: ______Campus: ______

D.O.B.: ______Grade: ______

Teacher: ______Service Requested (OT/PT):______

Reason for Referral:

What specific task(s) related to the student’s educational program are of concern?

(Ex. Written communication, recreational movement, etc.) ______

How specifically does this interfere with the student’s educational program? ______

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How has this need been documented through the IEP and what strategies have been utilized? ______

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For what length of time? ______

Outcome: ______

Areas Of Concern: (Check those that apply)

* These areas of concern frequently interfere with the student’s ability to participate and/or perform independently within the educational context.

____ Sensory Awareness/Processing (ex. Avoids or craves movement; aversion to light touch; poor balance; dislikes loud or unexpected sounds; does not notice details; poor sucking; chewing or swallowing skills) Other: ______

____ Gross Motor (ex. Bumps into desks, walls; falls out of chair; trips, stumbles or falls easily; tires easily—ex. unable to maintain an upright posture in order to complete a task or assignment; inability to access areas due to joint limitations; difficulty moving around school environment i.e. classroom, P.E., cafeteria, restroom, playground; difficulty getting in and out of chair; difficulty opening doors)

Other: ______

____ Fine Motor (ex. Switches hands and/or uses hands ineffectively—after age six; immature grip; hand shakes when writing; difficulty manipulating fasteners—after age seven; difficulty manipulating classroom materials; difficulty performing “hold and do” activities; difficulty remaining within boundaries when cutting or coloring—after the age of six; difficulty catching a ball; inability to cross midline with either hand –i.e. switching tools to other hand to avoid crossing midline of the body.) Other: ______

____Oral Motor (ex. Drooling; eating with mouth open; primitive reflexes such as tongue thrust &/or rooting reflex). Other: ______

___ Perceptual Skills (ex. Difficulty self regulating – ability to get to maintain or change how alert a person feels; loses place on page; poor body scheme – difficulty drawing a person with critical parts past the age of five; difficulty organizing and managing materials; lack of understanding of relationships of objects to each other and self – ie dressing, puzzles, writing within the margins). Other: ______

___Adaptive Behavior (ex. Skills needed to fulfill student roles and responsibilities in the schools, including social interaction and conduct, problem solving and coping behavior, and self control. *At age sixteen the role of community worker also assumes a major role). Other: ______

Name/Position of person completing this form Phone:

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