School OT Referral Form
Use this form to refer a student for occupational therapy support and describe the concerns, observed impact, and supports already tried.
Student Information
Student Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Grade Level
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
School Name
*
Teacher/Advisor Name
Parent/Guardian Name
*
First Name
Middle Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
*
example@example.com
Referral Details
Referral Date
*
 -
Month
 -
Day
Year
Date
Referring Staff Member Name and Role
*
Referral Source Type
*
Teacher
Counselor
Administrator
Parent/Guardian
Student Support Team
Other
Primary Reason for OT Referral
*
Observed Concerns and Functional Impact
Areas of Concern
*
Fine motor skills
Handwriting
Grasping tools
Sensory processing
Attention to task
Self-regulation
Motor planning
Coordination
Organization
Posture/endurance
Activities of daily living at school
Classroom participation
Other
Examples and Observations
Educational Impact Level
*
Mild
Moderate
Significant
Interventions Tried and Supporting Information
Interventions/Accommodations Tried
*
Response to Interventions
*
Improved
No Change
Worsened
Not Sure
Current or Prior OT/Related Services
None
School OT
Private OT
Other
Additional Notes
Submit Referral
Should be Empty: