1 Child’s name Gender DOB Post code Name of Primary Carer: Contact numbers: Relationship to child or young person: Email address (required): Address: Parental responsibility? Yes No Name of other carer/significant adult: Contact numbers: Relationship to child or young person: Email address: Address: Parental responsibility? Yes No Siblings: name: DOB: School: Health? School Details: GP Details: ST HELENS NEURODEVELOPMENTAL PATHWAY - REFERRAL FORM for Pathway Admin Office Use Only
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ST HELENS NEURODEVELOPMENTAL - REFERRAL FORM · ADHD Autism Spectrum Disorder language Attachment difficulties Alcohol Global Development al delay Speech and and communication Foetal
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1
Child’s name Gender DOB Post code
Name of Primary Carer: Contact numbers: Relationship to child or young person: Email address (required): Address: Parental responsibility?
Yes No Name of other carer/significant adult: Contact numbers: Relationship to child or young person: Email address: Address: Parental responsibility?
Yes No Siblings:
name: DOB: School: Health?
School Details:
GP Details:
ST HELENS NEURODEVELOPMENTAL PATHWAY - REFERRAL FORM for Pathway Admin Office Use Only
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Adopted Looked After Child
EHCP/ Provision agreement
Child Protection Plan
EHAT / Child In Need
Interpreter - Language required
Yes No
Agencies- *By signing the consent form on p3 you agree to us contacting and obtaining information from the below agencies (as required)
Child’s ethnicity:
White British Asian or Asian British Indian
Irish Pakistani
Gypsy/Roma Bangladeshi
Any Other background Any other Asian background
Mixed White & Black Caribbean Chinese
White & Black African Any other ethnic group
White & Black Asian Black or Black British Caribbean
Any other background African
Any other Black background
Agency/Service Already known? Y/N
Named professional/ Contact Number
Children’s Disability Service
Speech and Language Therapy
Occupational Therapy
Additional Needs Team
School or College
Hospital Consultant
Educational Psychology Service – including EHCP advice reports / assessment
Community Paediatrician
Child and Adolescent Mental Health (CAMHS)
Barnado’s
Social Care
GP
School Nurse
Language and Social Communication Team (LASC)
Other services
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PARENT/CARER CONSENT FORM FOR THE ST HELENS NEURODEVELOPMENTAL PATHWAY
FOR MULTI-AGENCY INFORMATION SHARING
Purpose: The sharing of information between agencies is an important part of the assessment of your child, as it provides a fuller picture of your child’s strengths and needs. Sharing information allows for a range of specialised assessments to be undertaken to help determine the needs of your child. In order for a full assessment regarding neurodevelopmental differences to be undertaken, several agencies may need to become involved. Consent: We need your consent to share information between agencies. The agencies covered by this consent to information agreement are detailed on Page 2 of the referral form. (Social Care including ICS records)
St Helens Neurodevelopmental Pathway uses the World Health Organisation, (1992) International classification of diseases: Diagnostic criteria for research (10th edition) (ICD-10), and the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (2013) (DSM V) tools for diagnosing autism spectrum disorder / attention deficit hyperactivity disorder /. As per NICE (National Institute Clinical Excellence) Guidelines (2011), these are nationally recognised tools within the UK for diagnosis of autism
Should a diagnosis of any condition be confirmed, mutual agreement of referral to other services to provide post diagnosis support to school / home would be arranged if required.
The consent for St Helens Neurodevelopmental Pathway will apply until your child is closed to this service. Many thanks for your cooperation.
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Parental/carer views Do you require support completing this form? Y/N ____________
(Must be completed by parent / carer) You may attach additional sheets if necessary. Please describe current concerns about your child in relation to their: Social interaction / communication (How they relate to friends / use of non-verbal communication (eye contact / gesture) / language development etc.) Behaviour (tantrums / play skills / empathy skills / routines / repetitive behaviours etc.) Attention / concentration / impulse control (energy, organisation and ability to sit and complete tasks) Sensory differences (smell, clothing, noises etc.)
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Please describe your child’s current living circumstances. Any significant life events encountered? Anything else you would like to tell us? Brief history of development (age when concerns began / prematurity/ age achieved milestones / speech development / play skills / physical health issues? etc.) Strengths and interests (what is your child good at?) What does your child do after school / weekends? Does your child have peer relationships / friendships? What do they do together?
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Referrers concerns (MUST be completed by professional): Person making the referral Designation and agency
Contact telephone number: Email address:
Please describe your concerns regarding this child’s (attach additional sheets if required):
Social interaction (awareness of others / interest in people / seeking comfort /empathy skills /awareness of feelings and emotions /
Social communication (use of language for range of functions / topic selection / selection and maintenance of conversation
/awareness of listener / vocabulary development / voice control, tone, volume, rate, expression / response to interaction / understanding of complex and non-literal language /understanding of gesture, tone and facial expression.)
Flexibility of thought (pretend play / imagination / need for routine / resistance to change /repetitive or stereotyped behaviour /
obsessions or movements / all consuming interests)
Attention, hyperactivity and impulse control (attention and concentration / focus on task / hyperactivity, fidgeting, frequent
body movements / forgetfulness / day dreaming / emotional dis-regulation / lack of sense of danger / organisational skills / peer relationships / oppositional behaviour)
Language (level of understanding, speech clarity, expressive language skills, selective mutism, fluency (stammering)).
Address:
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Physical health (diagnosed conditions, treatment, medications, hospital admissions, impact, sleep)
Learning / development (school performance, attendance, current support etc)
Family circumstances (bereavements, marital breakdown, parental mental health / domestic violence / social care
involvement / alcohol / addiction, SEN etc.) What do you suspect is the child’s current difficulty? (Please tick)
ADHD Autism Spectrum Disorder
Attachment difficulties
Global Development
al delay
Speech and language
and communication
Foetal Alcohol
Syndrome
As a referrer, I have discussed the following with parents:
The Pathway is unable to offer direct support to the parent/ carer/ child. They must be signposted to the appropriate services.
If the child’s needs can be met by another service, the pathway will end at that point and the case will be closed.
If a risk is identified by the referrer this must be managed and referred on to the most appropriate agency to support the child / family.
The assessment via the Pathway will determine whether their child meets criteria for a diagnosis of neurodevelopmental disorder. Individual agencies will make their own recommendations.
I have discussed with parents that the process may take some time and the services to which the Pathway refers usually have waiting lists of their own.
Referral date: Signature:
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Referral Application Checklist
Please attach any appropriate reports / assessments in respect of the child/ young person. The more information you can provide, the more efficient the assessment process
Parent screening questionnaire ESSENTIAL
School screening questionnaire ESSENTIAL
SNAP IV Forms (ESSENTIAL if ADHD suspected)
General Development Assessment (Bridge Centre assessments)