Your full name:

Relationship to child/young person 

Email Address:

Phone number:

Name of child/young person: 

Date of birth of child/young person:

What are your main concerns/challenges/ differences/ reasons for the assessment regarding the child/young person?

How long have these concerns been present for? 

Has the child/young person’s nursery/ college/ school expressed any concerns? 

What type assessment are you considering? (Autism, or ADHD, or cognitive assessment for learning disability, or a combined assessment, or not sure)  

What are your main goals that you would like to achieve? 

Does the child or young person have any existing diagnoses? 

Please outline if any other professionals have been involved with your child/young person in the past or currently, and outline the reasons for this (such as Psychologist, Psychiatrist,  Speech and Language Therapist,  Occupational Therapist, Child and Adolescent Mental Health Services (CAMHS), Social Worker, Physiotherapist, Counsellor / Therapist, Other)

Has your child/young person had a GP or CAMHS referral for an NHS Assessment? (if yes, please provide further information):

Does your child/young person have any prior or current medical or mental health concerns? (such as: genetic conditions, developmental delay, dyspraxia, non-verbal, learning disability, physical disability, learning needs, dyslexia, sight or hearing issues, or any mental health concerns, such as low mood, self-harm, anxiety etc. (please outline): 

1. My child notices small sounds when others do not?

2. My child usually concentrates more on the whole picture, rather than the small details?

3. In a social group, my child, can easily keep track of several different people’s conversations?

4. My child finds it easy to go back and forth between different activities?

5. My child does not know how to keep a conversation going with his/her peers?

6. My child is good at social chit chat?

7. When my child is read a story, he/she finds it difficult to work out the characters intentions and feelings?

8. When my child was in preschool, he/she used to enjoy playing games involving pretending with other children?

9. My child finds it easy to work out what someone is thinking and feeling just by looking at their face?

10. My child finds it hard to make new friends?

1. Does your child have difficulty concentrating, or are they easily distracted?   

2. Is your child often fidgety, or do they seem to be always on the go mentally or physically?  

3. Does your child often do or say things without thinking, or finds it difficult to wait their turn, or finds it difficult to wait to speak?  

4. Have the difficulties been present for more than 6 months?   

5. Do these difficulties occur in more than one setting, such as at home and school/college/work/education (i.e., across two environments)?   

6.  Were these difficulties present before your child was 12?      

If no or don't know, (to question 6), please provide further information):