XX, 2014

Re: Student XX
DOB: Month, day, year
Request for referral to XX Preschool Assessment Clinic
Student is a lovely little boy who has joined our inclusive preschool program at
XX School. He was identified as having significant delays as per the attached
report in the areas of language, motor, social awareness, and self-care. He
qualified for Program Unit Funding support (PUF) and receives intensive
preschool programming as well as Speech-Language and Occupational Therapy
support.
Students school team feels he will continue to require intensive supports and
would like to request a physician referral to the Glenrose Preschool Assessment
Clinic. Student demonstrates significant difficulty managing the routines of the
classroom independently and requires adult support and intervention throughout
his day. He is also impacted by a severe receptive and expressive language
delay, which influences his ability to communicate with others and understand
verbal directions. Student presents with rigid response patterns and
perseveration on topics of interest. He experiences difficulty with reciprocal play
and interaction with his peers can be frustrating for him.
Thank you in advance for your consideration of this request. Please feel free to
contact us if you require further information. You may attach the summary note
to your referral letter as consented by Students parents.
Sincerely,
Alison Lessard
Early Learning Coordinator

Mrs. X
Preschool Teacher

Ms. Sensory
Occupational Therapist

Ms. Language
Speech and Language Therapist

Student XX
Date:
DOB: (4 years: 2 months)
Request for referral to XX Preschool Assessment Clinic
Self-care Skills: Student is in the process of being toilet trained and requires one
on one support in a private washroom for bathroom routines. He uses visual
supports for washing hands and toileting. He finds the noise level in the boys
bathroom overwhelming and prefers the private washroom. Student rarely eats
snack at school, but with adult prompting will eat a few bites and then prefers
continue to play. Student requires adult support and visual/verbal cues for
dressing routines.
Classroom Behaviors: Student is experiencing difficulty following simple
directions in the classroom. He requires modeling, visual cues, and verbal
prompts throughout his day. He struggles with sustaining attention to classroom
instruction and requires one on one support from a staff member to follow
routines and complete simple tasks.
Communication Skills: Mrs. Speech, the classroom Speech and Language
Therapist completed the CELF-P2. Results indicated a severe receptive and
expressive communication delay. Student currently uses single or two words
sentences such as Bear look. With modeling he will attempt two to three word
phrases such as I want please. Student has a limited repertoire of
functional communication and his language is imitative and scripted. Unless
visually supported, his understanding is significantly challenged. He is able to
follow simple directions such as sit down but experiences difficulty with longer
requests. At times Students decreased attention influences his ability to follow
more complex directions or academic requests.
Fine and Visual Motor Skills: Mrs. Sensory, the classroom Occupational
Therapist, completed The Peabody Developmental Motor Scales 2 (PDMS-2).
Students overall results were in the 1st percentile (grasp in the 1st percentile and
visual motor integration at the 5th percentile). Occupational therapy support is
available in the classroom and Student is exposed to a variety of fine and gross
motor activities. Student has difficulty sustaining attention for fine motor tasks.
He benefits from cues to stop, look (observe demonstration) and do. Student
often resists fine motor tasks and comforting, preferred toys are used to keep him
motivated to attend for short periods of time. Student requires modeling and
support to target an object for coloring. Assistance is needed to place scissors
on his hand and with support for positioning, Student is able to randomly snip a
strip of paper. He is not yet able to draw a vertical or horizontal line.
Gross motor skills have not been formally assessed due to language delays,
decreased attention/impulsivity, high activity level, and noncompliance. Motor

planning delays may be present but at this time are difficult to assess because of
language and attention concerns.
Social Interaction and Play: Student is interested in play and he gravitates
toward the animal toys in the classroom. He experiences difficulty sharing with
other students and has a tendency to collect preferred toys, grab them from
others, and sometimes when redirected will hit the adult who is intervening.
Typically Students play is solitary and involves collecting and grouping animals.
Student will share toys with adult prompting and physical redirection, but will
sometimes hover as he watches a peer play with the shared toy and attempt to
retrieve it. He is beginning to move toward imaginative play (puppy eat, puppy
drink, puppy kiss) with visual supports and modeling, however it is difficult for him
to expand his play further. Classroom transitions are supported with prior warning
and adult supervision.
Concept Development: Student is able to label all colors and shapes. With one
on one support he is able to participate in circle activities and learning tasks. He
enjoys singing, music, and movement during circle time activities. Waiting his
turn and sitting for longer periods of time is difficult for Student. He benefits from
consistent redirection and routine expectations. He requires prompts and one on
one adult support to follow through on one step directions.
Student will continue to benefit from exposure to preschool concepts and
activities this year. As he transitions to Kindergarten for the 2015-2016 school
year, it is expected he will require ongoing intensive programming with supports
in all developmental areas.
Alison Lessard Early Learning Coordinator