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Knights of Columbus Developmental Center
Physician Referral Form

The Knights of Columbus Developmental Center at SSM Health Cardinal Glennon Children's Hospital is dedicated to providing comprehensive care for children with developmental disorders. This form is to be completed by the referring physician only. Thank you for choosing to refer your patient!

*Denotes a required field

Patient Information

 

Consultation Request Information

*Has family been informed of the reason for this referral?
* Has child been previously evaluated for/or diagnosed with autism?

Reason for Referral

* Please choose only one of the assessment options below. This will ensure that your patient is getting the specific services that they need.

Autism Spectrum Disorder Assessment
  • Poor functional communication
  • Limited social interaction with peers and/or adults
  • Poor interest/desire to perform age appropriate activities of daily living (i.e. dressing)
  • Atypical behaviors which may include: hand flapping, hand/body posturing, peering at objects, limited or atypical play
    with toys
Developmental Delay Assessment
  • Persistent delays in at least two areas (fine motor, gross motor, speech, language)
  • May have associated physical impairment, chromosome/genetic abnormality, neurologic signs
  • Social delays consistent with developmental level of functioning
Occupational Therapy Assessment - fine motor, sensory, self-care, feeding
  • Sensory processing difficulties, bothered by or seeking sound/touch/movement, constantly on the move, food
    texture/taste sensitivities
  • Poor functional daily living skills, buttoning, bathing and/or dressing difficulties, self-feeding difficulties
  • Fine motor limitations, pencil grasp, difficulty manipulating objects/play materials
*Has the patient been assessed by OT?
*Is the patient currently receiving OT services?
*Has the patient been assessed by Speech Therapy?
*Is the patient currently receiving Speech Therapy services?

Required Orders

Developmental and Autism evaluations often include multiple disciplines. The following orders must be completed with a diagnostic code and signature as this will serve as a signed prescription.

The following needs would be better served through referral to the following departments
  • Psycho-Educational Testing ➞ Psychology Department | 314-577-5667
  • ADHD Testing ➞ Psychology Department | 314-577-5667
  • Behavior Treatment ➞ Psychology Department | 314-577-5667
  • Speech/Language Delays Only ➞ Speech Department | 314-577-5669
  • Gross Motor/Fine Motor Difficulties ➞ PT and OT Therapy Department | 314-577-5669

Screening Completed

Please check all screenings which have been completed and indicate whether the child passed or failed. Please send copies of evaluations.

Modified Checklist for Autism in Toddlers (M-CHAT)
Conner's/Vanderbilt Behavior Ratings Scales

Parent:

Teacher:

Ages and Stages Questionnaire (ASQ)

Social and Communication Questionnaire (SCQ)

Pertinent Medical History (including psychiatric hospitalization)
Concerns Related to Family/Social History (E.g., Abuse/Neglect, Out of Home Placement)

Current Diagnoses (if any)

Laboratory or Radiological Studies Completed

Please check studies which have been completed, and indicate whether they were normal or abnormal. Specify all abnormal results.

EEG
MRI brain
Vision Screen
Hearing Screen
Chromosomal Testing

Electronic Signature

*I certify that the information in this form is true and correct to the best of my knowledge. I understand that if I knowingly provide untrue information in this referral form, this patient will be ineligible for participation. I understand that by entering an electronic signature and checking the box, I am submitting a legal signature.