Physical Therapy Referral Form

______

PHYSICAL THERAPY REFERRAL FORM

Secondary

Student’s Name: ______ / Grade: ______
Date of Birth: ______ / Teacher: ______
Date: ______ / School: ______

Dear Teacher,

Observation of a student’s behavior in the classroom is particularly helpful in determining the need for Physical Therapy services. The following items are related to the learning process. Please read through the categories and think about how this child performs in the classroom as compared to the other children. Check the appropriate current level of performance below as compared to peers.

Strength and Endurance / Average / Mild Difficulty / Significant Difficulty
Tires easily during gross motor activities
Tires with classroom ‘sit-down’ activities
Avoids gross motor activities and balance
activities (i.e. climbing, jumping)
Has difficulty carrying weighted objects (i.e chairs, trays, backpacks)
Has difficulty fully participating in class walks or gym class; walks last in line
Sits or leans at every opportunity
Has difficulty moving from sitting to standing (using arms for additional support to move)
Has difficulty pulling / pushing doors open
Has difficulty turning a doorknob and opening a door
Holds onto supports when putting on or removing coat, backpack, shoes
Muscle Tone and Postural Stability / Average / Mild Difficulty / Significant Difficulty
Demonstrates weak grasp
Body movements seem floppy
Fidgets and can’t hold position (i.e. wiggles when sitting, changes positions frequently, slumps in chair)
Uses whole body rather than just hands to
perform action
Has difficulty standing still, pushing and pulling
Pushes up from the desk when standing up from the chair
Has difficulty getting up and down from the floor
Postural Flexibility / Average / Mild Difficulty / Significant Difficulty
Changes positions frequently when expected toremain still
Movements appear rigid or stiff
Poor coordination in running, batting, kicking
Shifts side to side when doing pencil and paper tasks
Unable to reach over head to get objects off a shelf or catch a ball
Turns whole body to see something, not just his/ her head
Has difficulty picking up an object dropped onto the floor (i.e. pencil, papers)
Posture and Orthopedic Status / Average / Mild Difficulty / Significant Difficulty
Has difficulty sitting cross-legged
Doesn’t ‘fit’ classroom chair (i.e. with buttocks back, feet on floor, back erect)
One side of body (arm or leg) doesn’t work as well as the other side
Stands with slumped or tilted posture
Legs turn in or out when standing or walking
Back appears hunched, swayed or twisted
Foot ‘slaps’ when walking
Walks on toes
“W” sits (sits on bottom with knees together and feet turned outward making a “W” shape)
Wears braces on arms or legs
Prone to injury or broken bones
Balance / Average / Mild Difficulty / Significant Difficulty
Has difficulty going up or down stairs or stepping over objects on the ground
Falls out of chair, falls down easily
Fails to use arms to protect self when falling
Avoids balance activities
Walks or stands with hands in a mid-to-highposition
Stands or walks with wide base of support, toes point outward or inward
Has difficulty squatting
Has difficulty getting into/ out of car or bus
Gross Motor and Movement Quality / Average / Mild Difficulty / Significant Difficulty
Appears clumsy, awkward, bumps into things, trips often
Holds on when standing up from chair or floor
Movements appear jerky, fast, uncontrolled
Walks on toes, lacks bilateral arm swing, feet drag or slap, limps
Has difficulty with hopping, jumping, standing on one foot
Is fearful of movement
Walks more slowly than peers in crowded hallway
Demonstrates difficulty with movement activities in class and in the hallways
Negotiates crowded hallways and keeping up with peers in hallway
Difficulty managing backpack, locker, water fountain
Difficulty managing lunch tray
How do these problems affect the student’s classroom behavior and academic performance?
Please list any accommodations that have been initiated so far.
Specific activities this student is having difficulty performing.
Comments/ Questions.