Primary School Form – Class teacher & the learning support/resource teacher(s)

Referral Form for a Psychological Assessment Private & Confidential


    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:
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