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CDC Referral Form

CDC Referral Form

Step 1 of 9

About the child

Please comment on each section if relevant, or write 'no concerns'.

M/F

Referrer and contact details

So we know who to reply to.

School, home and GP

Reason for referral

Already known to Services?

Communication

Please comment on the following sections if relevant or write 'no concerns'.

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

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

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

Motor and self-help skills

Please comment on the following sections if relevant or write 'no concerns'.

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

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

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

Sensory, attention and early cognition

Please comment on the following sections if relevant or write 'no concerns'.

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

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

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

Review your answers

Please check everything below before submitting. You can go back and change any section — nothing is lost.

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