CDC Referral Form

CDC Referral Form
Name of person being referred
Name of person being referred
Name
Surname
Gender

Main Reasons for Referral

Already known to services?

Please comment on the following sections if relevant or write ‘no concerns’

Speech sounds

  • Is speech mostly clear and intelligible for unfamiliar listeners?
  • Are there any sound substitutions, omissions, or stammering behaviours?
Language 

  • Does the child use single words, short phrases, or full sentences?
  • Any use of signs, visuals, AAC
  • Can they follow instructions and answer questions

Interaction with others

  • How does the child engage with adults and peers?
  • Joint attention, play skills, turn-taking, sharing?
  • Do they imitate actions in play

Fine Motor Skills

  • Can the child manipulate small objects (e.g. threading beads, using crayons)?
  • Hand preference

Gross Motor Skills

  • Can the child walk, run, jump, climb?
  • Balance, coordination, motor planning?

Self-Help Skills

  • Level of independence with dressing, feeding, toileting?
  • Can they follow simple hygiene routines?
Sensory Processing

  • Does the child show strong reactions to noise, textures, smells, movement?
  • Example: Avoids messy play, distressed by loud sounds, craves movement?

Attention & Behaviour

  • Is the child able to focus during structured or play activities?
  • Any behaviours of concern (e.g. emotional outbursts, rigid routines, 

Early Cognitive Skills

  • Can they complete simple puzzles or matching activities?
  • Do they recognise and name colours, shapes, or familiar objects?