School multi/general referral form

If you are a teacher who has noticed concerns regarding a student’s development or behaviour but are unsure which specific services might be most appropriate, please use this form. This form will guide you through a set of questionnaires across all four disciplines: Occupational Therapy, Speech Pathology, Physiotherapy, and Psychology. Your responses will help us determine which disciplines could best support the student’s needs. Additionally, if you believe a student may benefit from more than one discipline, you can use this form to indicate multiple areas of concern. This allows you to provide comprehensive information without needing to complete separate forms for each discipline. Thank you for your detailed observations—they play an essential role in helping us identify the most effective support for your student.

Step 1 of 7

14%

Referral Information

Childs Name(Required)

First Last

Date of birth(Required)

MM slash DD slash YYYY

Class

Current School(Required)

Teacher's Name(Required)

First Last

Teacher's Email(Required)

Please select the area/s for referral

By selecting from the following options, you will be offered the corresponding questions, please select all that apply.

Occupational Therapy

Speech Pathology

Physiotherapy

Psychology

Unsure (all sections will be available to answer)

The following concerns relate to Occupational Therapy

Child's Skills

Please select the appropriate box if you have concerns for the areas below. A space is left below for any additional comments. Please note that this is a general referral form used for all ages and as such the child may not be at the developmentally appropriate age expected for completing stated task.

Motor Skills

Immature pencil grasp

Pencil pressure on paper too heavy/light

Low endurance during fine-motor tasks (e.g. when writing)

Difficulties with pencil control (e.g. colouring-in, drawing lines/shapes, tracing)

Does not use non-preferred hand to assist and stabilise

Does not demonstrate consistent hand preference/swaps hands

Avoids fine motor activities (e.g. drawing, writing, cutting)

Difficulties cutting with scissors

Difficulties with construction games (e.g. Lego)

Difficulty with fundamental movement skills (e.g. hoping, skipping, jumping)

Difficulties with ball skills (e.g. throwing/catching)

Poor posture (e.g. slouches, rest head in hands, holds head close to paper)

Difficulties with activities requiring rhythm and coordination (e.g. clapping games)

Avoids or is slow to learn new games or movement tasks

Difficulties with buttons, zips, tying shoelaces, opening containers/lunch box

Sensory Processing

Puts non-food objects in mouth and suck/chew on them (e.g. clothing, fingers)

Can become upset or distressed by loud noise and may put hands over ears

Can get distracted by visual information in the classroom e.g. another child, posters around the room

Frequently moves around the classroom and has difficulty sitting still on the mat

Is fearful when feet leave the ground and dislikes ‘moving’ playground equipment e.g. swings

Reacts emotionally or aggressively when touched, or getting hands dirty, playing with sand/Play Doh

Misses verbal instructions or appears to ignore or tune you out

Displays the need to frequently touch objects/people

Frequently plays or fiddles with objects

Presents lethargic or under-reactive in classroom

Behavioural/Social/Emotional

Difficulty separating from parent/carer

Dependent on adult company and support

Highly distractible, short attention span or impulsive behaviour

Over-reactive/under-reactive or passive

Does not relate well to peers

Difficulty following group routine

Difficulty transitioning between activities

Lack of age-appropriate play skills

Inappropriate/immature behaviour

Difficulties managing emotions

Cognitive/Perceptual

Difficulties following multi-step instructions

Difficulty with organisation and/or time management

Difficulties copying from the board

Unable to discriminate between left/right

Lacks body awareness or may demonstrate poor spatial awareness in drawings (e.g. stumbles, bumps

into things/people)

Difficulty coping simple lines and shapes ( - I O + / X ∆)

Difficulties with puzzles

Handwriting

Difficulties with letter formations

Inconsistent sizing and placement of letters

Frequent letter and/or number reversals

Difficulties with punctuation and spacing

Self-care skills

Difficulties opening containers or lunchbox

Difficulties zipping and un-zipping school bag

Difficulties managing buttons, zips and other clothing fastenings

Difficulties putting on socks and shoes, including tying shoelaces

Unable to toilet independently

The following concerns relate to Speech Pathology

This checklist aims to provide information about the concerns of the teacher and/or family regarding the child’s communication skills. It assists the speech pathologist to provide a targeted speech/language and/or literacy assessment tailored to the student’s needs. Please mark (tick) the appropriate box if you have concerns for the areas below. A space is left below for any additional comments. Please note that this is a general referral form used for all ages and as such the child may not be at the developmentally appropriate age expected for completing stated task. Please tick the relevant statements below regarding the reasons for referring this student.

Articulation (Speech Sounds)

Listeners have difficulty understanding the child’s speech.

Difficulties with producing 1 or more speech sounds (/p/, /b/, /t/, /d/, /n/, /m/, /w/,/h/, /s/, /f/, /k/, /g/, /sh/, /l/, /r/, blends /sp/, /st/ etc. and /th/)

Expressive Language (Grammar and Vocabulary; Retelling stories)

Leaves out words or uses telegraphic or abbreviated sentences. For example, “He patting cat” rather than “He is patting the cat”.

Makes errors with pronouns. For example, uses “him” instead of “he”, “he” instead of “she”, or “me” instead of “I”.

Makes errors with verb tense, such as “ing” and “ed” word endings being left off or incorrectly added. For example, “I rided my bike”.

Mixes up the order of words in sentences. For example, “I like lollie blue”.

Uses very few connector words such as “and” and “because”. Leaves them out or uses incorrect words. For example, “The boy go up the ladder. He need to get the cat” instead of “The boy is going up the ladder because he needs to get the cat”.

Has a limited vocabulary and may overuse nonspecific words such as “this”, “that”,

“thing” or “stuff” and/or may present with word finding or naming difficulties.

Difficulties telling stories, retelling events or sharing news. May lack important details, be out of sequence or confusing.

Receptive Language (Comprehension and understanding)

Difficulty understanding concepts. For example, size concepts such as “big” and “little”, “long” and “short”, or descriptive concepts such as “soft” and “hard”.

Difficulty understanding prepositions such as “in” , “on”, “under”, “behind”, “between”, “next to”.

Difficulty following instructions with 2 or more steps, such as “Get your drink bottle and line up”.

Difficulty answering “what”, “where”, “who”, “when” and “why” questions.

Literacy (Phonological awareness, Reading, Spelling, Written expression)

Difficulty with identifying letters and sounds

Difficulty with identifying beginning and end sounds of spoken words

Difficulty with segmenting and blending sounds in words

Makes spelling errors not expected for year of schooling and despite having received phonics instruction

Does not apply sounding out skills to reading and spelling tasks

Difficulties with using punctuation in writing despite receiving classroom instruction.

Difficulties with structuring of writing into sentences (year 1-2) and/or paragraphs (year 4 and above).

Social Thinking and Social Skills

Difficulty with initiating conversations, asking questions or taking turns in conversation

Speaks on one topic at length despite disinterest from others

Poor use of eye contact

Unexpected body proximity or leaving a group or room without explanation or appropriate farewell

Voice

Husky, croaky or hoarse voice observed. Also recommend GP referral to ENT (Ear, Nose and Throat specialist.

Stuttering

Stuttering such as word or sound repetitions (“I I wa want to…”) , prolongations (“Mmmmister”) or blocking before onset of word observed.

The following concerns relate to Physiotherapy

Please mark (tick) the appropriate box if you have concerns for the areas below. A space is left below for any additional comments. Please note that this is a general referral form used for all ages and as such the child may not be at the developmentally appropriate age expected for completing stated task.

Core Strength

Unable to sit on the mat or at a desk for the required period of time (or to the same extent as their peers)

“W sitting” position when sitting on the floor

Poor posture when sitting at the desk (slouching, leaning on arms, wrapping legs around chair legs)

Muscle Strength

Fatigues quickly when participating in games with peers

Difficulties with jumping (poor vertical height, horizontal distance and simultaneous push off/land) with good foot clearance

Difficulties with taking weight through arms

Pain in arms and/or legs

Gross Motor Skills

Toe walking

Difficulties with jumping

Difficulties with hopping

Difficulties with catching from 2 metres

Difficulties with throwing accurately to a target 2 metres away

Difficulties with kicking

Difficulties with playing in physical games with peers

Unable to run or fatigues quickly when running

Difficulties with planning movement or copying movement patterns

Difficulties with coordination

Playground Safety

Slips, stumbles or trips frequently on the playground

Difficulties with using all age-appropriate playground equipment

Difficulties with climbing down ladders safely (i.e. backwards)

Difficulties with riding a bike or scooter

Frequently jumping from high heights

Unaware of others around them on the playground

Bumps into things

The following concerns relate to Psychology

Please mark (tick) the appropriate box if you have concerns for the areas below. A space is left below for any additional comments. Please note our services may not be suitable in all cases, as our clinicians have specific areas of experience. We are unable to assist with complex trauma/PTSD (including sexual abuse), bipolar disorder, psychosis, eating disorders, substance use issues, crisis needs (such as ongoing safety risks or domestic/family violence), significant family distress affecting child care and ability to attend appointments, or forensic needs. Thank you for understanding.

Academic Concerns

Difficulty concentrating

Difficulty organization and time management

Declining academic performance

Frequent difficulty with complete tasks/assignments

Other (please specify)

Other

Please Specify

Behavioral Concerns

School refusal

Difficulty separating from parents

Difficulty with school transitions

Disruptive in class

Struggles with compliance/resistant when feeling overwhelmed or misunderstood

Difficulty following instructions

Responding to frustration with physical behaviour

Responding to frustration with verbal irritation

Other (please specify)

Other

Please specify

Emotional Concerns

Mood swings/low mood

Anxiety or worry

Grief

Persistent sadness or withdrawal

Excessive anger or irritability

Low self-esteem

Other (please specify)

Other

Please specify

Social Concerns

Difficulty making or keeping friends

Social withdrawal or isolation

Subject to bullying behaviors

Engaging in bullying behaviours

Difficulty with social skills or peer relationships

Difficulty with life transitions

Other (please specify)

Other

Please specify

Physical/Sensory Concerns

Unexplained physical complaints (e.g., stomach aches, headaches)

Noticeable changes in appearance/hygiene

Sensory sensitivities (e.g., to noise, touch)

Tired in class/not sleeping well

Other (please specify)

Other

Please specify

Any other comments regarding the child’s strengths or areas of difficulty?

How we use this information

The information you provide in this form is confidential and used solely to evaluate the child’s needs and determine suitability for therapy services. Thank you for choosing Down South Therapy, we look forward to working together to make a positive impact.

Consent(Required)

Please complete the following information to confirm you have discussed these concerns with the parent/caregiver and have consent to submit this referral.

Please check this box to confirm that you have discussed these concerns and recommendations with the parent/caregiver of this child

Please check this box to confirm that you have obtained consent from the child’s parent/caregiver to submit this referral.

Please check this box to confirm that you have informed the parent/caregiver that Down South Therapy will contact them upon receiving this referral.

Caregiver's Name(Required)

First Last

Caregiver's Email(Required)

Caregiver's Contact Number(Required)

Comments

This field is for validation purposes and should be left unchanged.

0/5 (0 Reviews)

As a mobile service, we are committed to going the extra mile, quite literally, to cater to your needs. Our dedicated team will travel directly to your location, ensuring that individuals residing in the South Metropolitan, Eastern Corridor, Peel Regions, and the South West of Western Australia have easy access to the full spectrum of essential service provisions. Your well-being is our top priority, and we are proud to serve these regions with unwavering dedication and commitment.