School age referral pack for parent/carer and child/young person · Web view2021/06/14 · 4 word...

School age referral pack for parent/carer and child/young personFor Rotherham Child and Adolescent Mental Health Service - Neurodevelopmental Pathway (Autism and ADHD Assessment service)

We believe the best approach for referral into the service is for schools/settings and parents to work together to complete the referral pack. Practitioners working with families, children and young people in situations where this is not possible are encouraged to contact us for advice before referring (for example, if the child is electively home educated).

Referrals will only be accepted using the referral packs. It is expected that the referring practitioner will coordinate the completion of the pack, which includes various questionnaires for the school/setting, parents/carers and in some instances, the young person to complete. The completed referral pack will then need to be emailed to [email protected]

Please be aware we prefer electronic referrals to postal referrals as this reduces the misplace of information

On receipt of the fully completed referral pack, the Social and Emotional Wellbeing Panel will screen these to assess whether further neurodevelopmental assessment is appropriate. The panel includes Rotherham representatives from Educational Psychology, Speech and Language Therapy, Specialist Inclusion Team, Children's Disability Family Support & Autism Information and Advice Service along with the CAMHS Neurodevelopmental Assessment service.

If we review all the information and decide that the evidence suggests that the young person does not need further neurodevelopmental assessment, then they will not be added to the waiting list for this and their referral to the neurodevelopmental assessment pathway will be closed. However, we will make recommendations of further support or assessment that may be helpful.

Page 1

mailto:[email protected]

Contents

List of sections in this pack:

School age referral pack for parent/carer and child/young person..............................1Important actions:........................................................................................................3

1. Parent / Child Pack Checklist:........................................................................3Parent / carer and child pack.......................................................................................4

2. Children and young people’s neurodevelopmental service............................4Child’s details.......................................................................................................4Consent................................................................................................................5

3. Childhood Developmental Questionnaire.......................................................6Person completing this form.................................................................................6Tell us about your child/young person..................................................................6Adults Living at Home...........................................................................................8Medical history....................................................................................................11Child Development.............................................................................................13Do you have any concerns about any of the following?.....................................16

4. Your child’s education:.................................................................................175. Family Life....................................................................................................186. Relationships with peers...............................................................................197. Childhood ADHD Symptoms Scale - Self- Report........................................208. Young person’s screening questionnaire......................................................219. ADHD Screening Questionnaire (Snap-IV)...................................................22

ASD Screening Questionnaire – Parent Version................................................24

Page 2

Important actions:It is expected that the referring practitioner will coordinate the completion of the packs. Please ensure you return your completed pack to the school/setting referrer so they can submit the referral.

We would advise saving these forms as they are updated so you do not lose any information.

If you require any support in completing this pack, please speak to either the referrer in the first instance or contact the neurodevelopmental co-ordinator who can signpost accordingly.

1. Parent / Child Pack Checklist:

Consent form - Parent and/or Young Person (aged 14 upwards) - to complete

Childhood development questionnaire - Parent to complete

Childhood ADHD Symptom Scale (Self-report) - Young person aged 12 – 18 years to complete

Current ADHD Symptom Scale – Young person aged 12 – 18 years to complete

Young person’s screening questionnaire (Please note this form is NOT compulsory for those under 12 and should be completed by the young person)

ADHD Screening questionnaire – Parent to complete

ASD Screening questionnaire – Parent to complete

Page 3

Parent / Carer and Child pack2. Children and young people’s neurodevelopmental service

Consent form – parent and/or young person (aged 14 upwards) to complete

Child’s details

Child’s name: Click or tap here to enter text.

Date of birth: Click or tap here to enter text.

NHS Number: Click or tap here to enter text.

Address: Click or tap here to enter text.

Home telephone or contact number: Click or tap here to enter text.

Name of school/setting: Click or tap here to enter text.

Name of school/setting contact: Click or tap here to enter text.

Name and address of GP: Click or tap here to enter text.

Language spoken at home: Click or tap here to enter text.

Religion: Click or tap here to enter text.

Ethnicity: Click or tap here to enter text.

Is your child:

Adopted? ☐Fostered? ☐in special guardianship? ☐

Has your child previously been assessed in relation to ADHD or ASD?Yes ☐ No ☐If yes, please include when/where and who by:

Click or tap here to enter text.

Page 4

Consent

I hereby give consent for the Rotherham CAMHS Neurodevelopmental Service to:

Obtain reports from other agencies and practitioners: Yes ☐ No ☐Pass on information which may be helpful to the practitioners

at school/setting: Yes ☐ No

☐

Contact the GP: Yes ☐ No ☐Contact the Hospital: Yes ☐ No ☐Please provide name of consultant (if applicable): Click or tap here to enter text.

Contact Social Services: Yes ☐ No ☐Please provide name of social worker (if applicable): Click or tap here to enter text.

Contact the Educational Psychologist: Yes ☐ No ☐Contact any other relevant organisation: Yes ☐ No ☐

Sign or print name: _____Click or tap here to enter text.___________________

Date: Click or tap to enter a date.

Page 5

3. Childhood Developmental Questionnaire

Parent to complete.

To help us understand your child / young person’s needs, we require some detailed information about their difficulties and family circumstances. We are aware that we are asking for some very sensitive personal information. This information will help us both to process the referral into the service and aid in the assessment process which involves reviewing information at the Social and Emotional Wellbeing panel. The completed form will be saved onto your child / young person’s RDASH medical records. Sensitive personal information will not be shared with other agencies (e.g. school) without your consent/ consent of the child/young person (if appropriate) – unless there are safeguarding concerns.

Person completing this form

Name: Click or tap here to enter text.

Date of birth: Click or tap here to enter text.

Relationship to child: Click or tap here to enter text.

Contact number: Click or tap here to enter text.

Tell us about your child/young person

What are the biggest challenges for your child/young person right now?Click or tap here to enter text.

Page 6

When did you first have concerns and what has happened since then?Click or tap here to enter text.

Please tell us about any actions or steps you use at home to support your child?


Please tell us about your child/young person’s strengthsClick or tap here to enter text.

Page 7

Adults Living at Home

Please tell us who has Parental Responsibility (PR). Please give contact numbers for main carers. (Leave blank if not applicable).

Parental Responsibility

Name Date of birth Relationship to child (PR)

Address if different from above

Contact numbers





















Page 8

Are there other important adults in your child’s life (e.g. other parent if you are separated or a grandparent)? (Leave blank if not applicable).

Other important adults

Name Date of birth Relationship to child (PR)

Address if different from above

Contact numbers





















Separated parents – please tell us about any shared care / contact arrangements: (Leave blank if not applicable).


Page 9

Please provide details of any siblings: (Leave blank if not applicable)

Name Date of birth

School Any health / learning needs

Living at home





Yes ☐ No ☐





Yes ☐ No ☐





Yes ☐ No ☐





Yes ☐ No ☐

Page 10

Medical history

Pregnancy details Yes/No Please use this column to explain further

Any previous miscarriages or stillbirths?

Yes ☐ No ☐ Click or tap here to enter text.

Was the pregnancy with your child planned?


Did mother have any fever or infection during the pregnancy?


Did mother have medical or mental health difficulties during the pregnancy?


Did mother require medication during the pregnancy? (e.g. sodium valproate, gentamicin)


Did mother drink alcohol during the pregnancy?


Did mother smoke cigarettes during the pregnancy?


Did mother use street drugs during the pregnancy?


Were there any concerns about baby’s growth or health from antenatal scans?


Page 11

Birth details: Please use this column to explain further:Were there any complications during pregnancy?


Was baby born at full term of pregnancy?

Yes ☐ No ☐

If not, how early or late were they?


Was the delivery: Normal ☐Forceps ☐Vacuum ☐C-Section ☐

Were there any complications during birth?


Did the mother have a difficult labour?


How long was labour? Click or tap here to enter text.

Birth weight: Click or tap here to enter text.Please give details of any difficulties after birth:


Did the baby require special neonatal care / support?


Did mother have any postnatal depression?


Page 12

Child Development

Please state at what approximate age your child did the following

Age

Holding their head up whilst lying on their tummy: Click or tap here to enter text.

Sitting up straight without using their hands for support: Click or tap here to enter text.

Rolling over from back to tummy: Click or tap here to enter text.

Crawling: Click or tap here to enter text.

Walking alone without support: Click or tap here to enter text.

Playing with sounds or seeming to make words: Click or tap here to enter text.

Speaking single words consistently to mean someone or something:


Calling themselves ‘I’ or ‘me’ more often than their own name:


Speaking 3 to 4 word sentences: Click or tap here to enter text.

Smiling freely and intentionally towards you and others:(e.g. smiling at you when seeing you after you’d been away for a while/smiling back at you after you’d smiled at your child/smiling as a reaction to you talking or playing etc.)


Showing you things by pointing at them and looking back at you:


Playing games like peek-a-boo: Click or tap here to enter text.

Playing with objects by pretending to talk: (e.g. talking on the phone/feeding a doll/flying a toy aeroplane etc.)


Pretending objects are something during play: (e.g. banana is a telephone etc.)


Staying dry during the day: Click or tap here to enter text.

Staying dry during the night: Click or tap here to enter text.

Page 13

Did your health visitor have any concerns about your child’s progress in their early years?


Has your child ever had speech and language assessments or therapy?

Yes ☐ No ☐

Further info?


Page 14

Child’s health Yes / No If yes, please give detailsEver been admitted to hospital?

Yes ☐ No ☐ What happened?Click or tap here to enter text.

Ever had any seizures, fits, faints, or other loss of consciousness?


Any other medical conditions or problems?


Ever had a head injury? Yes ☐ No ☐ Click or tap here to enter text.

Had a hearing test? Yes ☐ No ☐ If yes, please provide details of when and what the results wereClick or tap here to enter text.

Had a vision test? Yes ☐ No ☐ If yes, please provide details of when and what the results wereClick or tap here to enter text.

Any medication / food allergies?


Are immunisations / vaccinations all up to date?


Are any prescribed or over-the-counter medications taken regularly?


Page 15

Do you have any concerns about any of the following?

Concern Please give detailsAppetite? Click or tap here to enter text.

Diet? Click or tap here to enter text.

Sleep? Click or tap here to enter text.

Coordination and balance?


Use of self-care skills? (e.g. eating / feeding / dressing / using cutlery / toileting)


Unusual sensitivity to noise / taste / texture / pain?


Tics / nervous habits? Click or tap here to enter text.

Obsessions / compulsions?


Repetitive or unusual behaviours?


Problems with mood and / or self – esteem?


Specific fears / phobias?


Page 16

4. Your child’s education:

Nursery / school attended

Years attended

Any concerns raised
















Has your child had any extra help at school with their learning, behaviour, or other issues? Yes ☐ No ☐

If yes, did it help? Please provide details:


Have you / your child had any assessments or help from other agencies such as educational psychology, social services, etc? Yes ☐ No ☐

If yes, did it help? Please provide details:


Page 17

5. Family Life

Does anyone living at home have any physical health problems or disabilities that regularly affect day-to-day life?


Is there any family history of Autism / ADHD / dyspraxia / anxiety /other mental health difficulties / disabilities /learning difficulties /other conditions? If yes, whom?


Have there been any major events that may have been stressful for the family? (e.g. moving home / physical or mental health difficulties /deaths of family members /separations or divorce / unemployment /legal / financial problems)


Page 18

6. Relationships with peers

Do you have any worries or concerns about your child’s relationships with other children of about the same age?(e.g. bullying/aggression, frequent fall-outs, being easily led or vulnerable, getting involved in risk-taking or inappropriate behaviour with other children)


Does your child/young person find it easy to make / keep friends?


Do they get invited to other children’s parties or play / social activities?


Is there anything else you think is important for us to know?

Please use this space to describe any other concerns you may have or information you think would be helpful. It might be useful to tell us what other family members and other adults who know your child tell you about them. (Please note that we will be requesting a separate detailed report from your child’s school)


Page 19

7. Childhood ADHD Symptoms Scale - Self- Report

For the young person (aged 12-18) to complete

Name: Click or tap here to enter text.Date: Click or tap here to enter text.

Please check the box that matches the number that best describes your behaviour when you were a child aged 5 to 12 years – please use the key provided:

Key:Never or rarely: 0 Sometimes: 1Often: 2Very often: 3

Nev

er o

r ra

rely

Som

etim

es

Ofte

n

Very

ofte

n

Tota

l

Failed to give close attention to details or make careless mistakes in my work ☐ ☐ ☐ ☐Fidgeted with hands or feet or squirm in seat ☐ ☐ ☐ ☐Difficulty sustaining my attention in tasks or fun activities ☐ ☐ ☐ ☐Left my seat in classroom or in other situations in which seating was expected ☐ ☐ ☐ ☐Didn’t listen when spoken to directly ☐ ☐ ☐ ☐Felt restless ☐ ☐ ☐ ☐Didn’t follow through on instructions and failed to finish work ☐ ☐ ☐ ☐Had difficulty engaging in leisure activities or doing fun things quietly ☐ ☐ ☐ ☐Had difficulty organising tasks and activities ☐ ☐ ☐ ☐Felt “on the go” or “driven by a motor” ☐ ☐ ☐ ☐Avoided, disliked, or was reluctant to engage in work that requires sustained mental effort ☐ ☐ ☐ ☐Talked excessively ☐ ☐ ☐ ☐Lost things necessary for tasks or activities ☐ ☐ ☐ ☐Blurted out answers before questions had been completed ☐ ☐ ☐ ☐Easily distracted ☐ ☐ ☐ ☐Had difficulty awaiting turn ☐ ☐ ☐ ☐Forgetful in daily activities ☐ ☐ ☐ ☐Interrupted or intruded on others ☐ ☐ ☐ ☐

8. Young person’s screening questionnaire

Page 20

For the young person (aged 12-18) to complete

Name: Click or tap here to enter text.Date: Click or tap to enter a date.

THIS FORM IS NOT COMPULSORY FOR THOSE UNDER 12

In order to better understand your current situation, we would appreciate if you could take a few minutes to complete this form. This information will be looked at by our team to help process the referral that has been made. This information will be stored securely as part of your NHS record.

Please tell us why you think you have been referred to this service?


What do you think would be helpful for you?


Is there anything else you would like to share?


Page 21

9. ADHD Screening Questionnaire (Snap-IV)

James M. Swanson, Ph.D., University of California, Irvine, CA 92715

Parent to complete

Completed by: Click or tap here to enter text.

Date: Click or tap to enter a date.

For each item, check the column which best describes this child / adolescent:

Key:Never or rarely: 0Sometimes: 1Often: 2Very often: 3

Nev

er o

r ra

rely

Som

etim

es O

ften

Very

ofte

n

Tota

l

Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks

☐ ☐ ☐ ☐

Often has difficulty sustaining attention in tasks or play activities

☐ ☐ ☐ ☐

Often does not seem to listen when spoken to directly ☐ ☐ ☐ ☐Often does not follow through on instructions and fails to finish schoolwork, chores, or duties

☐ ☐ ☐ ☐

Often has difficulty organizing tasks and activities ☐ ☐ ☐ ☐Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort

☐ ☐ ☐ ☐

Often loses things necessary for activities (e.g. toys, school assignments, pencils or books

☐ ☐ ☐ ☐

Often is distracted by extraneous stimuli ☐ ☐ ☐ ☐Often fidgets with hands or feet or squirms in seat ☐ ☐ ☐ ☐Often leaves seat in classroom or in other situations in which remaining seated is expected

☐ ☐ ☐ ☐

Often runs about or climbs excessively in situations in which it is inappropriate

☐ ☐ ☐ ☐

Often has difficulty playing or engaging in leisure activities quietly

☐ ☐ ☐ ☐

Often is “on the go” or often acts as if “driven by a motor” ☐ ☐ ☐ ☐

Page 22

Often talks excessively ☐ ☐ ☐ ☐Often blurts out answers before questions have been completed

☐ ☐ ☐ ☐

Often has difficulty awaiting turn ☐ ☐ ☐ ☐Often interrupts or intrudes on others (e.g., butts into conversations/ games

☐ ☐ ☐ ☐

Often loses temper ☐ ☐ ☐ ☐Often argues with adults ☐ ☐ ☐ ☐Often actively defies or refuses adult requests or rules ☐ ☐ ☐ ☐Often deliberately does things that annoy other people ☐ ☐ ☐ ☐Often blames others for his or her mistakes or misbehaviour ☐ ☐ ☐ ☐Often is touchy or easily annoyed by others ☐ ☐ ☐ ☐Often is angry and resentful ☐ ☐ ☐ ☐Often is spiteful or vindictive ☐ ☐ ☐ ☐

Page 23

ASD Screening Questionnaire – Parent Version

Parent to complete

Your name: Click or tap here to enter text.

Relationship to Child: Click or tap here to enter text.

Date of completion: Click or tap to enter a date.

This form asks about behaviours in several areas where children may have difficulty. Please could you read each of the statements and rate the extent to which they apply to this child, referring to the key at the top of the pages. Please feel free to add any additional information or comments in the margins or in the spaces provided. If a statement is not applicable for any reason, please write n/a.

Please use the blank page at the end of the form if you need extra space or to describe any other behaviour that you would like us to know about.

Page 24

SOCIAL INTERACTION(How do they relate of others and show emotion)

Doe

s no

t ap

ply

Som

ewha

t app

lies

Neu

tral

App

lies

to

som

e ex

tent

Def

inite

ly

appl

ies

Makes eye contact when speaking with or listening to another person

☐ ☐ ☐ ☐ ☐

Points to and shares things of interest with others

☐ ☐ ☐ ☐ ☐

Plays in a repetitive or inflexible way and / or has a tendency to control others

☐ ☐ ☐ ☐ ☐

Understands ‘unwritten’ social rules – e.g. how close to stand, how to get attention before talking, what level of familiarity is OK

☐ ☐ ☐ ☐ ☐

Shows an interest in interacting and forming relationships with other children – e.g. spending break / lunch times together in school or arranging to meet up out of school.

☐ ☐ ☐ ☐ ☐

Please give an example in this space:


Appears to prefer interaction and relationships with adults to spending time with other children

☐ ☐ ☐ ☐ ☐

Approaches to other children tend to be one-sided, clumsy, or insensitive – e.g. can say the wrong things

☐ ☐ ☐ ☐ ☐

Makes and keeps friendships with children of approximately the same age

☐ ☐ ☐ ☐ ☐

Shows a range of emotional expressions that match the situation – e.g. smiling, frowning, expressing different emotions through their eyes and facial expressions

☐ ☐ ☐ ☐ ☐

Is able to understand and respond to how other people might be thinking or feeling – e.g. Trying to comfort someone in distress, doing something because they think the other person will like it

☐ ☐ ☐ ☐ ☐

Is able to share in other people’s enjoyment ☐ ☐ ☐ ☐ ☐Please add any other comments about, or give examples of, your child’s relationships or interaction with adults or peers. If you have more to add please use the blank page on the back of this document.


Page 25

SOCIAL COMMUNICATION(How do they communicate)

Doe

s no

t ap

ply

Som

ewha

t ap

plie

s

Neu

tral

App

lies

to

som

e

Def

inite

ly

appl

ies

Imitates sounds, words, and movements of others

☐ ☐ ☐ ☐ ☐

Responds to facial expressions, gestures, and different tones of voice used by others

☐ ☐ ☐ ☐ ☐

Responds to their name being called by turning and making eye contact with the person calling their name

☐ ☐ ☐ ☐ ☐

Shows facial expressions to others intended to display the emotions they are feeling

☐ ☐ ☐ ☐ ☐

Uses a variety of gestures alongside speech – e.g. pointing, nodding head, using hands to show the size of something

☐ ☐ ☐ ☐ ☐

Uses unusual ‘turn of phrase’ or repeats specific words / phrases (may include phrases or dialogue from TV).

☐ ☐ ☐ ☐ ☐

Speech is unusually monotonous ☐ ☐ ☐ ☐ ☐Speech is excessively formal – e.g. uses vocabulary that seems more sophisticated than usual for someone of their age or for the situation

☐ ☐ ☐ ☐ ☐

Is able to have to-and-fro conversation with another person on a range of topics, at a level you would expect for someone of their age

☐ ☐ ☐ ☐ ☐

Likes to chat just to be friendly (rather than only when something is wanted). Shows an interest in the thoughts, opinions, and feelings of others

☐ ☐ ☐ ☐ ☐

Tends to ‘lose’ people in conversation – too much detail, sudden change of topic, or takes no account of the listener’s previous knowledge

☐ ☐ ☐ ☐ ☐

Please add any other comments about, or give examples of, how this child communicates. If you have more to add please use the blank page on the back of this document:


Page 26

Page 27

PATTERNS OF BEHAVIOUR/ INTERESTS/ ACTIVITIES(How they play, react to new experiences and changes in routine, move their body, and use their senses of vision/hearing/touch/smell) D

oes

not

appl

y

Som

ewha

t ap

plie

s

Neu

tral

App

lies

to

som

e ex

tent

Def

inite

ly

appl

ies

When playing with objects, tends to get focussed on very specific details or parts of the object

☐ ☐ ☐ ☐ ☐

Please give specific examples in the space below:


Plays imaginatively and flexibly – play varies play and uses toys or other materials to represent something they are not e.g. using a banana as a phone or microphone

☐ ☐ ☐ ☐ ☐



Takes part in pretend make-believe play (which is not based on parts of movies or TV shows)

☐ ☐ ☐ ☐ ☐

May show worry about the same thing over and over again

☐ ☐ ☐ ☐ ☐

Changes to routines and unexpected events cause upset and distress more than you would expect

☐ ☐ ☐ ☐ ☐

Has specific routines or specific ways things must be done by themself or by others.

☐ ☐ ☐ ☐ ☐



Has special interests or topics which are unusual in their focus or intensity – e.g. dinosaurs, trains, clocks, weather, license plates.

☐ ☐ ☐ ☐ ☐



Page 28

Has unusual ways of moving fingers, hands, arms, legs; or spins or rocks body.

☐ ☐ ☐ ☐ ☐



Is overly sensitive to some sounds, smells, or textures – seeking some out, actively avoids others

☐ ☐ ☐ ☐ ☐

Has an unusual response to touch – may overreact to touch or pain, or may not respond to things that others would find uncomfortable or painful

☐ ☐ ☐ ☐ ☐

Please add any other comments about, or give examples of, your child’s relationships or interaction with adults or peers. If you have more to add please use the blank page on the back of this document:


Please use this space to describe any other unusual behaviour you have noticed that you would like to tell us about. Please list the specific behaviour and give an example or two:


Page 29

Date post:	18-Jul-2021
Category:	Documents
Upload:	others
View:	1 times
Download:	0 times

School age referral pack for parent/carer and child/young person · Web view2021/06/14 · 4 word...

Documents