Richland County School District One Special Education Department
OCCUPATIONAL THERAPY/PHYSICAL THERAPY
Screening Request Form

Referring Source to complete this section:
School: Teacher: Grade:
Student's First Name: Middle: Last:
Birthdate: Race: Sex: Nickname:
Medicaid#: Social Security#:
Address: Home Phone:
City: Zip: Work Phone:

Parent:                                                                                   [   ]Parent          [   ]Guardian      [    ]Surrogate
Please check all services student is currently receiving:
  Regular Class Placement   Special Education Placement
  Speech/Language Therapy   Resource Room (Handicap__________)
  Itinerant Orthopedic Services   Self-Contained (Handicap___________)
I.Q. (if known): Date of Test:
Health Problems (include medication):
 
Screening requested:   Occupational Therapy   Physical Therapy
Reason for screening:
 
Referring Source: Position: Date:
Parent/Guardian Permission to Screen: Date:

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Therapist to complete this section:             
Recommendations:
  Occupational therapy evaluation not indicated
  Physical therapy evaluation not indicated
  Student needs P. T. evaluation.  Please send parent permission form and Physician's referral.
  Student needs O.T. evaluation.  Please send parent permission form and Physician's referral.
Comments:
 
Therapist: Date:
Therapist: Date:

Return to: Karen Jenny @ Fairwold School, 5935 Token St., Columbia, SC  29203 (Mail Code 460)

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Student's Name:

Directions:  Please fill out as completely as you can. Your perception of this child's difficulties in school are vital to pertinent evaluation by a physical or occupational therapist.

1.  General medical information (serious illnesses, fractures, surgeries, seizures, headaches, loss of consciousness, previous therapy).

2.  Special equipment? (brace, splint, glasses, etc.)

3.  Any difficulties with feeding? (cup, fork, spoon, drooling, amount of assistance)

4.  Any problems you have noticed in the classroom, or other pertinent information, that we should consider in evaluating this child?

REASON FOR REFERRAL: (PLEASE CHECK ITEMS WHICH BEST DESCRIBE CHILD'S BEHAVIOR)

  NONE MILD MOD SEVERE
GROSS MOTOR PERFORMANCE OBSERVATIONS:
1.  Child falls easily        
2.  Clumsiness in walking, running, use of stairs, etc.        
3.  Cannot perform motor skills as expected for age as hopping, skipping, running, jumping        
4.  Child appears to be weak, fatigues easily        
5.  Child moves stiffly, rigid, or tense movements        
6.  Difficulty with ball skills        
FINE MOTOR SKILLS:
1.  Holds pencil, crayon, or chalk awkwardly        
2.  Strokes too heavily or too lightly        
3.  Has difficulty using scissors        
4.  Has difficulty with printing or writing        
5.  Inconsistent hand preference-switches hands        
6.  Difficulty with shoe tying, buttons, zippers, etc.        
BEHAVIORS WHICH MAY BE ASSOCIATED WITH MOTOR PROBLEMS:
1.  Moves impulsively with little judgement        
2.  Runs into persons or things        
3.  Avoids certain motor activities if possible        
4.  Poor attention, easily distracted        
5.  Difficulty following motor directions        
6.  Seems to need to feel or touch things before reacting        
7.  Over reacts to touch or physical contact, may hit out or withdraw        

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