Primary School Form – Class teacher & the learning support/resource teacher(s) Referral Form for a Psychological Assessment Private, confidential, and without prejudice Please fill in all fields marked with an * * Your Name: * Contact Number: * Childs Name: * Childs Date of Birth: * Address: * Parent(s) or Guardian(s) Name: * Telephone Number(s): * Parent/Guardian Email Address: * School Name: * Class/Year: * School Address: * Roll Number: * Name of Principal: * School Telephone Number: * School Email Address: * What is the main reason for this referral? LearningBehaviourEmotionalOther If other, please give Details: Is the child receiving: * Learning Support? YesNo * Resource teaching Support? YesNo If he/she is/has, please answer the following: Learning Support: In what subject(s)? How often weekly? Duration of classes? Resource teaching support: In what subject(s)/area(s) How often weekly? Duration of classes? Please include the results of Standardised tests done in the last 2 years. Date: Name of test: Results- give S.S. and percentile rank: Date: Name of test: Results- give S.S. and percentile rank: Date: Name of test: Results- give S.S. and percentile rank: Date: Name of test: Results- give S.S. and percentile rank: Please comment on the following * Attention/Listening: * Memory: * Concentration: * Oral skills: * Reading-Sight vocabulary: * Reading- Word attack skills-phonics: * Reading- Comprehension: * Mathematics- Computational skills: * Mathematics-Problem solving: * Spelling: * Writing skills: * Fine motor skills: * Gross motor skills: * Social skills with teachers/other adults: * Social skills with others his/her age: * Behaviour in class: * Behaviour in playground: * Is the child receiving any Speech and Language or Occupational Therapy interventions? If so, please give details: * Please give details of any in-school interventions being used with the child: please give details about the efficacy of these interventions etc.: Any additional information or comments: Consent I/We understand that the results of this evaluation will be made known to me/us, to the School Principal, and, where the parents and Principal deem it appropriate, to the relevant members of the school staff. Signature(s) of teachers completing this form: * Principal: * Learning Support teacher(s): * Resource Teacher(s): * Date: Please enter the letters below and then click on the send button.