Stars Rehabilitation for People of Determination

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Referral Form





    AutismLearning Disability

    NoneWheelchair

    MaleFemale

    What does your child have difficulty with?

    Self-managementBasic communicationDressingtoiletingGroomingBathing

    writingreadingmathsmemorylearningschool

    emotionalattentionsocial interactionplayingbehaviourfeedingmemory

    Basic mobilityShoppingMoney managementSocial awareness

    NoYes

    If yes, please specify: e.g. Autism, Attention deficit etc.

    NoYes

    If yes, please give names and dosages:

    NoYes

    If yes, please specify:

    Has your child received previous services? (Where and How long?)
    Developmental History
    We are aware that we are asking for a lot of information, which is why we are giving it to you to take home so that
    you have a bit of time to think it through. Please don’t worry if you cannot remember exact ages or details; what we
    are most interested in is whether or not you had concerns or comments about any of the items below, e.g. was your
    child late or early with anything. This information is important for us to fully understand your child’s profile.
    Birth History

    NoYes

    If yes please state:

    VaginalScheduled C-SectionEmergency C-SectionForcepsVentouses

    Length of pregnancy:
    Birth weight:

    NoYes

    If yes please state:

    Developmental Milestones (WTL= Within Time Limits)
    Motor (Age)
    Self Help Skills (Age):
    Gross Motor (Age):
    Fine Motor (Age):

    Right/leftInconsistentNot determined

    Toileting:
    Hearing /Vision:

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    NoYes

    Communication

    Age at which your child:

    NoYes


    Dear Parent/Carer,

    Thank you for completing this form. Please submit this form to Stars for Rehabilitation Center for People of
    Determination who will then contact you for an appointment at the earliest available opportunity.

    The information contained in this form is confidential and will not be distributed without your consent. Please be
    sure to provide any relevant reports and information prior to your appointment.

    We look forward to working with you and your child.

    Thank you.

    I confirm that I have received Stars for Rehabilitation Center for People of Determination policy and agree will the terms and conditions therein.