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?

CDC Referral Form

CDC Referral Form

Name of person being referred

Name of person being referred

Name

Name

Surname

Surname

Gender

Male

Female

Date of Birth of person being referred

Name of Referrer and Relationship to Client

Contact Number

Email Address

Current School (if applicable)

Home Address

GP Name and Address

Main Reasons for Referral

General Reason for Referral

Already known to services?

Yes, Please Specify:Yes, Please Specify:

No

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?

Speech sounds

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

Language

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

Interaction with others

Fine Motor Skills

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

Fine Motor Skills

Gross Motor Skills

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

Gross Motor Skills

Self-Help Skills

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

Self-Help Skills

Sensory Processing

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

Sensory Processing

Attention & Behaviour

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

Attention & Behaviour

Early Cognitive Skills

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

Early Cognitive Skills

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