Child's Name
Child's Date Of Birth
Your Name
Your Telephone Number
Your Email
Your Address
Does your child have an Education Health Care Plan (EHCP)?
Does your child have a diagnosis, and if so when was this received?
Please provide details of any current or previous intervention (e.g., behaviour, speech, occupational therapy, etc):
Please complete each of the following as currently applies to your child using scale:
Language & Communication
Says words
Indicates wants and needs non-verbally (by pointing, gesturing, etc)
Speaks in Sentences
Non-verbally imitates (copies actions)
Verbally imitates (copies speech)
Responds to simple everyday instructions
Receptively labels (naming by pointing, gesturing, etc)
Expressively labels (verbally naming)
Please complete each of the following as currently applies to your child using scale:
Social & Play
Rejects or disassociates from other children
Tolerates other children
Shows interest in or observes other children
Plays near or parallel to other children
Plays or interacts cooperatively with other children
Plays with simple toys appropriately
Plays simple games
Plays complex games or sports
Engages in pretend or imaginative play
Please indicate the current frequency with which your child engages in the following, and the intensity of the behaviour using the appropriate scale:
Behaviour
Frequency
Extent of Behaviour
Aggression
Self-Injury
Damage to Property
Meltdowns
Sleep Problems
Eating Difficulties
Non-Cooperativeness
Difficulties with Attention
Demand Avoidance
Tolerance Difficulties – e.g., change, transitions, etc
Sensory-Seeking Behaviours
Absconding (running away)
Please rate your child’s current capabilities, considering his or her age, in the following areas, using the scale:
Toileting
Feeding
Dressing
Bathing/Brushing Teeth
Chores
Safety
Please describe your child’s strengths, positive characteristics and qualities:
Please add any other information or relevant comments:
Once we have received your completed form, we will arrange for one of our senior clinical team to contact you to provide more information.
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