Child Referral Form for Therapy Services

 Male Female
What does your child have difficulty with?

 talking expressing self speech pronunciation stuttering understanding hearing loss

 writing reading maths memory learning school

 emotional attention social interaction playing behaviour feeding memory

 gross motor skills, e.g. walking, sitting, jumping fine motor skills, e.g. hand movements self-help skills, e.g. dressing, washing sensory problems(tactile, movement, visual, auditory)
 No Yes

If yes, please specify: e.g. Epilepsy, Diabetes etc.

 No Yes

If yes, please specify:

 No Yes

If yes, please give names and dosages:

Has your child received previous services? (Where and How long?)

 SLT OT PMT PSY SE Psycho-Educational Multidisciplinary Early Intervention


 English Arabic French


Developmental History (Where and How long?)
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.
 No Yes

If yes please state:

 Vaginal Scheduled C-Section Emergency C-Section Forceps Ventouses
Length of pregnancy:
Birth weight:
Were there any complications at or after your child’s birth? No Yes

If yes please state:

Developmental Milestones (WTL= Within Time Limits)
Motor (Age)
Self Help Skills (Age):
Gross Motor (Age):
Fine Motor (Age):
 Right/left Inconsistent Not determined
Hearing /Vision:
 No Yes
 No Yes
 No Yes
 No Yes
 No Yes
 No Yes


Age at which your child:

 No Yes

Dear Parent/Carer,

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 and your child.

Thank you.

 I confirm that I have received Stars policy and agree will the terms and conditions therein
 I give permission to Stars to liaise with my child’s school for relevant information and advice.
Policies Acknowledgement and Signature

Refund Policy

For payments in advance, a minimum of 5 weeks from the date of the request applies in order to proceed with the refund. Refund requests are to be made via Stars for Special Abilities email:

Cancellation Policy

Appointments are to be regarded as a contract between Stars for Special Abilities and Parents for the exclusive use of the therapists’ time.
All cancellations should be made at least 24 hours in advance by informing the Front Desk through phone or email at:
If notice has been given within less than 24 hours, the first cancellation will be charged half of the applicable rate. For the second cancellation and onwards, higher rates may apply. For assessments cancelled within less than 24 hours, an extra fee of AED 150 will apply for rescheduling. A minimum attendance of 80% is required to continue to receiving services from Stars for Special Abilities.

No-Show Policy

Appointments are to be regarded as a contract between Stars for Special Abilities and Parents for the exclusive use of the therapists’ time. If appointment is not attended (No-Show) without any prior notice, parents should be charged the full session rate.

Stars for Special Abilities reserves its right to consider refusing the services. For assessments not attended without any prior notice, an extra fee of 250 AED will apply for rescheduling. Services may be refused or discontinued due to non-payment, aggressive behavior or lack of cooperation.

By signing below, I acknowledge Stars for Special Abilities Refund, Cancellation, No-Show policies.

Parent Name:
Patient Name: