Adult Referral Form for Therapy Services

Please note some questions are asked for an either “yes” or “no” response: where appropriate please give a
description or details to these questions. Space is provided for you to do so. Thank you.

Developmental History

 Right Left

Have you ever had difficulty with the following areas prior to today?

 speech pronunciation mathematics gross motor skills understanding attention difficulty fine motor skills expressing social interaction hearing loss reading writing stuttering memory problem solving other


Medical History

 No Yes
if yes please provide the name and the dosage:

 No Yes
if yes please provide the name and the dosage:

To the best of your knowledge do you:


To the best of your knowledge do you:


 Audiologist Otolaryngologist (ENT) gross motor skills understanding Gastroenterologist Speech & Language Therapist Psychologist Optometrist Psychiatrist Psychomotor Therapist Neurologist Other

Educational History

 Primary/Elementary School Secondary/High School Undergraduate Post Graduate

Work History

 Yes No


 Yes No

Thank you for completing this form. Please submit this form to Stars for Special Abilities 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.

Thank you.

 I confirm that I have received Stars policy and agree will the terms and conditions therein