Occupational Therapy Referral Checklist

Santa Rosa City Schools Department of Special Services

This student may be considered for an OT evaluation. The information you provide is a very important part of that process. If the student is currently able to access the curriculum, and if appropriate and documented accommodations have not been tried for a reasonable period Debra of time, an OT evaluation is not recommended.

A copy of any accommodations that have been recommended and used with the student must be submitted with this checklist, before further consideration. Please, attach SELPA form 26b or SELPA 5a from the appropriate IEP, if one has already been completed for a student!!

must be completed before the student will be considered for an evaluation, if other documented accommodations do not exist in any form. It is important to note if the accommodation was helpful for curriculum access or not.

An OT observation may be performed before an evaluation when appropriate, upon review of this completed packet.

This information is intended to support the decision-making process, in deciding, when an OT evaluation may be appropriate to help a student meet their IEP goals:

When an OT Evaluation is Not Recommended 1. Problem does not interfere with student’s ability to participate in their educational program.

2. The unique expertise of OT is not required to meet the student’s identified need.

3. Other educational personnel are able to assist the student in areas of concern and do not require the expertise of an OT.

4. Problem is not caused by limitations in OT performance domains (ex. fine motor/utilizing educational materials/sensory processing/ ADLs related to school), that impede access to curriculum.

5. Potential for change is not likely or performance remains unchanged despite multiple efforts by teaching staff or previous therapists to remediate the concerns, or to assist the student in compensatory techniques.

6. Goals or outcomes requiring OT have been met and no additional goals are appropriate.

7. Problem ceases to be educationally relevant.

8. Therapy is contraindicated due to medical, psychological or social complications. OT Referral Checklist (Continued) Page 2

Why are you requesting that this student be evaluated by an occupational therapist? Please be complete and accurate. Attach additional pages including grade level performance in the areas of reading, math, spelling and writing. Also, include examples of handwriting/drawing samples. ______

Referral Information: Person Making Request: ______Position:______Signature: ______Date request submitted:______

Principal: ______Principal’s Signature: ______Comments: ______

Student Information: Name: ______Birth Date: _____ Gender: Male__ Female__ Grade: _____ School: ______General Education Teacher: ______Phone:______Special Education Teacher: ______Phone:______Language of Home: ______Student’s Preferred Language:______

1. Parent/ Guardian Information: Occupation: ______Name: ______Relation: ______Street: ______Home Phone: ______City, State, Zip: ______Work Phone: ______2. Parent/ Guardian Information: Occupation: ______Name: ______Relation: ______Street: ______Home phone: ______City, State, Zip: ______Work Phone: ______

Teacher Information Checklist This checklist must be completed and turned into the Special Services Department before an OT observation or evaluation will be initiated unless, other accommodation pages from an IEP have been provided with the referral packet, as stated on the first page. Please add when the accommodations were started and who was implementing and documenting the outcomes. Start date: ______Provided in: SDC classroom ____Resource room_____ Gen ed _____ Teacher Information Checklist Page 3

After checking the appropriate accommodations, please place a plus sign (helpful), or minus sign (did not help) next it, in order, to indicate if this was a successful strategy for the student.

Related to Support Response to Materials/Instruction ___Check for understanding ___Reduced/shortened assignments/tests ___Instructions/directions repeated ___Extended time -class assignments/tests ___Present one task at a time ___ Use of notes for tests/assignments ___Preferential seating______Open book for tests/assignments ___Supervision during unstructured time ___Spelling errors will not impact grade ___ Cues/prompts/reminders of rules/procedures when editing assistance is unavailable ___ Offer choices ___Use of a calculator ___Note taking assistance/notes provided ___Proof-reader and redo assignment ___Use of a scribe/word processing ___ Written mechanics not graded ___Peer tutor/staff assistance:______Graphic organizer ___Picture schedule ___Site word bank ___Other:______Enlarged text ___Prior or current Behavior Support Plan ___Books on tape ___Home/school communication system Settings ___Other:______Access to study carrel ______Free from visual distractions ___Break tasks into smaller units of work ___Quiet environment ___Small group environment Related to Writing Skills Related to Sensory Processing ___Pencil holder/grips ___ Providing breaks/ break cards ___Large primary pencils/weighted pencil ___Time out space provided in class ___Adapted paper (highlighted lines) ___Avoid messy task if sensitive to textures ___ Slant board ___Noise cancelling headphones ___Light sandpaper under writing surface ___Movement breaks over school day ___Work at easel ___Heavy work jobs (carry, push, pull, lifting) ___Dry erase board ___Oral fidget for mouth/crunchy snacks ___Rubber stamps-letters/numbers ___Air pillow for chair ___Word processor ___Sensory choice list on desk ___Other:______Other:______

Signed by staff who observed the student using the accommodations listed above:

Teacher: ______Date: ______

OT Referral Checklist Page 4

Please complete the following list in order to help determine the most appropriate course of action: OT observation/evaluation for the student, at this time.

Please check the following items that apply by frequency of occurrence, as observed: Frequently: F Sometimes: S Unknown: U Never: N

Please add, any relevant information in the Other area. More information is better. Thank you! Fine Motor Unable to complete written worksheets in class ___ Poor desk posture (slumps, leans on arms, head to close to work) ___ Poor pencil grasp- may be very loose or very tight (please circle) ___ Tight pencil grasp, fatigues quickly when writing ___ Changes grasp on pencil frequently ___ Pencil lines are wobbly, too faint, or too dark (please circle) ___ Writes very slowly or very quickly (please circle) ___ Difficulty using both hands to cut or manipulate materials ___ Does not cross midline of body (shifts body or switches hands) ___ Difficulty with dressing, buttons, zippers, or snaps ___ Other: ______

Visual Perceptual/Visual Processing Difficulty copying designs, letters or numbers ___ Difficulty in organizing letters/numbers on page ___ Reversals of words, letters, or numbers after first grade ___ Uses uppercase letters within words/case confusion ___ Difficulty copying off chalkboard ___ Cannot attend to a writing/drawing task for an extended time ___ Writes over letters/ poor word spacing/ writes in middle of page (please circle) ___ Misses written directions more than other students ___ Poor line alignment, letter sizing/spacing and word spacing when writing ___ Difficulty editing written work for corrections ___ Difficulty finding place on worksheets or assignments ___ Leaves items blank on busy worksheet even when he/she knows answer ___ Other: ______

Tactile (Touch) Processing Seems overly sensitive to being touched, pulls away from light touch ___ Tends to wear only certain type of clothing or fabrics ___ Has difficulty with keeping hands to self, will poke or push other children ___ OT Referral Checklist Page 5

Tactile (Touch) Processing Touches things constantly, seeks tactile input frequently ___ Avoids putting hands in messy substances ___ Has difficulty with controlling interactions in group games, when peers are close ___ Other: ______

Auditory Processing Has difficulty understanding or paying attention to what is being said ___ Misses oral directions more than other students ___ Easily distracted by sounds ___ Sensitive to noise/covers ears (bells, loud sounds) ___ Has difficulty following two-three step oral directions ___ Other: ______

Oral Motor/Processing Difficulty in chewing, swallowing, or drools (circle) ___ Chews on clothing/objects or fingers in mouth ___ Sensitive/avoids certain food textures/limited diet ___ Other: ______

Classroom Behavior Restless (squirmy in chair or on floor) ___ Gets up and moves around more than other students ___ Attention span considerably shorter than other students ___ Withdraws from activities/intentionally leaves active environments or situations ___ Has difficulty tolerating changes in routines, plans and expectations ___ Withdraws when there are changes in the environment or routine ___ Is bothered by rules being broken ___ Other: ______

Signed: ______Case/Program Manager for Spec Services

Date when all required referral information complete: ______

Thank you very much for taking the time to complete this information and returning it to the Special Services Department in a timely manner.