Occupational Therapy (OT) Referral Form - UCPS - Exceptional ...

UNION COUNTY PUBLIC SCHOOLS
PROGRAMS FOR EXCEPTIONAL CHILDREN
REFERRAL FOR OCCUPATIONAL THERAPY EVALUATION
PROCEDURE: This form is to be used by the intervention team or IEP team when classroom strategies have proven
unsuccessful in supporting the student’s participation in the areas identified below. For best results, an occupational therapist
should be present for the pre­evaluation meeting when this referral and Permission to Evaluate (DEC­2) are completed.
DATE PERMISSION TO EVALUATE SIGNED: _________________
DATE REFERRAL RECEIVED BY OT: __________________
SCHOOL: ________________________ TEACHER: ____________________ GRADE/RM#:_________
STUDENT NAME: ___________________________ DOB: _____________ SIMS/NCWise # _____________________
When is the classroom teacher available for a 15­30 minute interview?_____________________________
When is the student available for separate assessment? _________________________________________
Check the evaluation process the team is conducting for this student:
INITIAL EC EVALUATION EC RE­EVALUATION OTHER (explain) ______________________
If this student is already eligible for services through the Exceptional Children’s Program, list:
Area of Eligibilty _______________________________________ IEP Date _____________________
Current EC services/type/frequency/duration ________________________________________________
Please check each of the areas in which this student in not fully participating (underline specific areas):
Personal Care (feeding/lunchroom skills, toileting, clothing management, hygiene, managing personal belongings)
Student Role/Interactive Skills (management of classroom/school materials – bookbag, locker, art materials,
manipulatives, computer, communication device, papers/notebook, etc.; following routines; work
behaviors/organization ­ attending/completing, sequencing steps, transitions,etc.; social skills)
Learning/Process Skills (following demonstrations, verbal/written directions, initiation, visual perceptual skills such
as directionality in work, copying models, written organization, scanning/tracking skills, understanding spatial terms)
Play (taking turns, participating in groups/games, sharing materials, exploring new play ideas/opportunties)
Community Integration (fieldtrips, school­related vocational training)
Graphic Communication (pre­writing, handwriting, scissors skillls, keyboarding, art)
For each of the areas checked above, please identify specific ways this student requires more assistance than peers in
order to participate in that area:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________
Please identify strategies that have been unsuccessful in helping this student participate in that area:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
TEAM SIGNATURES: ___________________________________ _____________________________________
_______________________________________ _________________________________ _________________________