Occupational Therapy Assessment – Referral Form

Thank you for referring your child to My World Therapy. We look forward to meeting you and your child.

Occupational Therapy assessment explores whether there are any sensory or motor skills difficulties impacting upon a child’s participation at home or school.

Occupational Therapy assessment uses a range of standardised and non-standardised assessments to build an understanding of your child’s strengths and needs. Information is also gained through observation, parent/carer interview, teacher interview and sensory questionnaires. Once the assessment is complete, a report will be shared with you. Please fill in the Referral Form below and we will process your request.

Child's Name:

Date of birth:

Address:

Postcode:

Phone Number:

Names of Parents/Carers:

Your email address:

Diagnosis:

Past Medical History:

Known to Social Services? YesNo

Name & Address of School/Nursery:

Please give details of any Occupational Therapy related issues your child experiences:
Self-help skills (changing for PE, eating/drinking, toileting):

School skills (attention, handwriting, typing, planning/organisation):

Sensory Processing Difficulties:

Motor Skills Difficulties:

Other professionals involved with child:

Other relevant information:

I authorise the Occupational Therapist to perform assessments, carry out therapeutic interventions, provide recommendations, resources and training, as deemed necessary for my child. I understand this intervention may be carried out in my absence at school or nursery and that results of the assessment and the recommendations will be discussed with me.