RASHID CENTRE REFERRAL FORM SCHOOL PLACEMENT Please enable JavaScript in your browser to complete this form.Date of ReferralMaleFemaleAttending Nursery / School ?YesNoCARE GIVER / FAMILY INFORMATIONLanguage (s) Spoken At Home:ArabicEnglishOthersDoes Anyone Speak English?YesNoSCHOOL SERVICESSchool Placement (3 -18 yrs)YesArabicEnglishNeed Transportation?YesNoFURTHER INFORMATIONPhysicalSelf HelpIs your child walking independently?YesNoIs your child feeding him/her self?YesNoIs your child sitting alone?YesNoIs your child dressing him/her self?YesNoIs your child crawling?YesNoIs your child toilet trained?YesNoCommunication:Is your childnon-verbalusing single wordssentencesHave any Learning Difficulties been identified? If so, what are they?Referral filled out by: *Submit E-mail Address: info@rashidc.ae / Tel: 04-3400005 / Fax: 04-3402662
