OCCUPATIONAL THERAPY REFERRAL CHECKLIST - …

OCCUPATIONAL THERAPY REFERRAL CHECKLIST Student: _____ Date: _____ Date of Birth: _____ Case Manager: _____ Grade: _____ Teacher: _____ Other services child is receiving: _____ Please check all areas that apply and return to the OCCUPATIONAL therapist at your earliest convenience. Thank you. FINE MOTOR _____ Poor desk posture (slumps, leans on arm, head too close to work, other hand does not assist, sits on leg) _____ Difficulty drawing, coloring, copying, cutting, avoidance of these activities _____ Awkward pencil grip _____ Lines drawn are wobbly, written work is too dark/light; breaks pencil frequently _____ Written work is slow and labored _____ Tries easily when writing _____ Difficult

Developed by Mikki Harkin/2000 Occupational Therapy Referral Checklist Page Two ACADEMIC/ ORGANIZATIONAL BEHAVIOR _____ Marked mood variations

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  Checklist, Referral, Occupational, Therapy, Occupational therapy referral checklist

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