Referral Questionnaire | The Spark TS

Child's Preferred Pronouns Required

He/him

She/her

They/them

Other

Which of the following statements best describes your current situation?

My child has not accessed OT services previously.

My child is current working with another OT service but this will be changing.

My child has worked with an OT in the past and we are seeking service again.

Are you specifically seeking any of the following services?

Assessment (3-4 sessions)

Parent support/coaching

Group programs

Parent education (i.e online and in-person learning opportunities)

Foundation block of appointments (6 fortnightly sessions)

Safe and Sound Protocol

Friendship skills and social problem solving:

Self-regulation, emotional awareness and wellbeing:

Attention and executive function:

Play and Leisure:

Motor Skills:

Fine Motor skills – using hands and fingers to complete coordination tasks

Gross motor skills – whole body movements such as running, skipping, bike riding

Ball skills

Using classroom tools – pencil and scissors

Life Skills:

Developing independence at home, e.g. helping with domestic tasks, personal hygiene

Developing independence in the community e.g. public transport, shopping

Support with the following:

Sensory processing differences

Handwriting

Referral Questionnaire
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