Child Referral Form

Date:

passport-sized photo of child (jpg/png)

Emirates ID of the child (jpg/png)

Any assessment/medical reports of the child (pdf)

Child's name:

Birth date:

Age

Gender:MaleFemale

Nationality

First Language:

Second Language:

Grade:

School/Nursery:

Mother’s Name:

Age:

Occupation:

Mobile Number:

Email:

Fathers’s Name:

Age:

Occupation:

Mobile Number:

Email:

Home Address:

Home number:

Best time to call:

Form completed by:

Relationship to child:

Referred by:

Reason for referral:

What does your child have difficulty with?

Motor and Sensory:
gross motor skills, e.g. walking, sitting, jumpingfine motor skills, e.g. hand movementsself-help skills, e.g. dressing, washingsensory problems(tactile, movement, visual, auditory)

Others:

Does your child have a diagnosis?NoYes

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

Does your child take any medication?NoYes

If yes, please specify:

Previous Surgery/Surgeries?NoYes

If yes, please give names and dosages:

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

Speech & Language Therapy (SLT):

Psychology (PSY):

Occupational Therapy (OT)

Psychomotor Therapy (PMT)

Physio-therapy

ABA

Special Education (SE)

Preferred language for services:EnglishArabicFrench

Others:

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.

Were there any complications during pregnancy?:NoYes

If yes please state:

Length of pregnancy:

Birth weight:

Were there any complications at or after your child’s birth?NoYes

If yes please state:

Developmental Milestones (WTL= Within Time Limits)

Motor (Age)

Rolled over:

Sat alone:

Crawled:

Stood:

Walked:

Grasped Object:

Ran:

Gave object:

Stairs up:

Stairs down:

Self Help Skills (Age):

Fed self with fingers:

Fed self: Spoon

Drank: sippy cup:

Drank: cup:

Drank: straw:

Dressed: help:

Dressed: alone:

Tied Shoes:

Gross Motor (Age):

Jumped:

Rode a bike:

Kick a ball

Throw a ball:

Catch a ball:

Fine Motor (Age):

Palmer (fist) grasp:

Tripod grasp:

Used scissors

Colored in lines:

Printed name:

Writing (reversals)

Headedness:Right/leftInconsistentNot determined

Toileting:

Toilet with help: (Day)

Toilet with help: (Night)

Toilet independent: (Day)

Toilet independent: (Night)

Hearing /Vision:

Any concerns about his/her hearing? NoYes

Recent hearing test? NoYes

Grommets?NoYes

Have a history of ear infections? NoYes

Wear/need glasses? NoYes

Visual difficulties?NoYes

if yes please describe

Communication

Age at which your child:

Cooed:

Babbled

First words

Put 2/3 words together:

Used sentences:

Put sentences together:

Engaged in conversation:

Understood directions:

Pointed:

Does your child interact with others? NoYes

Sample of your child’s first words:

Other observations/concerns:

Please describe the concerns you have regarding your child. Is there anything else you think it is important for us know?

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.

Date:

Name:

Email:

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: admin@starzuae.com.

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: admin@starzuae.com.
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: