DOCTOR’S REFERRAL FORM

    Doctor's Name

    Doctor's Email

    ______________________________________

    Child's Name

    Date of Birth

    Parent's Name

    Address

    Phone Number

    ______________________________________

    Condition/ Diagnosis
    AutismAsperger’sSensory Processing DisorderADHDIntellectual ImpairmentHearing ImpairmentVision ImpairmentCerebral PalsyOther

    Other

    Presenting Concerns
    Gross Motor SkillsFine Motor SkillsLearningHandwritingSocial SkillsBehaviour IssuesToiletingFeedingMemoryAttentionOther

    Other

    Preferred Therapist
    Any suited therapist

    Additional Referral Notes

    Funding Plan
    Enhanced Primary Care PlanGP Mental Health Care PlanPrivately funded