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?
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.

Name of test:
Results- give S.S. and percentile rank:
Name of test:
Results- give S.S. and percentile rank:
Name of test:
Results- give S.S. and percentile rank:
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:


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.