TEACHER’S REFERRAL FORM

    Teacher's Name

    Teacher’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