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 differences 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 to provide us with the background information we need prior to the assessment.


    Child's Name:

    Date of birth:



    Phone Number:

    Names of Parents/Carers:

    Your email address:


    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 Differences:

    Motor Skills Differences:

    Other professionals involved with child:

    Other relevant information: