Family History Form London -

Family History Form - London

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Family History Form

Prior to completing this form, please view our Information Sharing Policy and Confidentiality Policy

Child's name

Child's date of birth

Name of parent/s or carer/s

Parent/s or carer/s email address

Child's home address

Please briefly outline your main concerns NOW regarding your child? (we will explore these together in detail during the assessment)

How long have these difficulties been present and do they interfere with your child’s daily functioning? Please describe

How old was your child when you first thought that their behaviour was different from that of other children? What did you notice?

Did you speak to a professional about your concerns? If yes, what type of professional did you speak to and what advice were you given?

What are your child’s particular strengths? (e.g. sport, hobbies, interests etc.)

What do they least enjoy doing?

Please provide the name of the school your child attends

Do you consent for us to contact the school (this is imperative for the Assessment to meet criteria)

Yes

Does your child have any specific learning difficulties/disabilities

Yes

If yes, please give details

Have you been asked to collect your child before the end of school due to his/her behaviour in class?

Yes

Has your child ever been officially excluded from school?

Yes

If yes, please could you state why, how many times or how often this has occurred and for how long?

Names of parent/s or carer/s

Ages of parent/s or carer/s

Occupations of parent/s or carer/s

Is the child an adopted child?

Yes

If yes, at what age were they adopted?

During pregnancy did you take any medicines/drugs (including illegal drugs)

Yes

If yes, please list

During pregnancy, number of cigarettes smoked daily

During pregnancy, alcohol consumption per day

Was your pregnancy full term?

Yes

If not, how many weeks early was the birth?

Any complications during pregnancy, birth and/or after delivery (any special care)?

Child’s birth weight

Did you feel low or unhappy after the birth or have post-natal depression?

Yes

If yes, how long did this last?

Please outline who lives in the family home (include ages of any other children, whether they are full or half-siblings, step-siblings or adopted siblings)

Please list any other siblings or half-siblings who do not live in the family home

Please give details of any neurodevelopmental difficulties (e.g. ADHD, ASD, Tourettes), mental health difficulties (e.g. Depression, Anxiety) or learning difficulties (e.g. Dyslexia) in biological parents, blood siblings or wider blood relatives (please state the relationship of the person with the difficulty to the child, e.g. cousin)

Does your child have any physical or mental health diagnoses?

Yes

If yes, please give details

Has your child ever had any serious illnesses or accidents/injuries?

Yes

If yes, please give details

How would you describe your child’s current bed-time and sleep pattern? (e.g. do they find it difficult to fall asleep and/or sleep through the night?)

What time do they typically go to sleep?

What time do they typically wake up?

Are they usually difficult to wake up and/or tired during the day?

Were there any concerns that your child was developing slowly? (e.g. sitting/walking)

How old was your child when they first walked unaided?

How old was your child when they started using single words (other than mum and dad)?

How old was your child when they started using two or three word phrases?

Has your child ever been referred to speech and language services?

Did you have any difficulty with potty training your child?

At what age did your child acquire bladder control by day (i.e stop having accidents)?

At what age did your child acquire bladder control at night (i.e stop having accidents)?

At what age did your child acquire full bowel control (i.e stop having accidents)?

Has your child experienced any significant life events or trauma? If yes, please describe

Have there been any particular difficulties with the following: Tying shoelaces, doing up buttons, handwriting, riding a bike, using playgrounds, using a knife and fork properly? Please describe:

Is your child able to dress him/herself without any help in the morning?

Yes

If not, why do you think that is?

Was your child an easy ‘cuddly baby’?

When can you remember them first smiling at you?

Did your child settle into a good routine as a baby? Please describe in more detail

Were there any problems with sleeping, feeding, crying or any other problems as a baby?

Was your child as a baby happy to separate from you / happy to be put down?

As a young child, what games did your child enjoy playing?

Did your child (when young) prefer to play alone or with others?

Did your child go to playgroup or nursery school? If yes, at what age did they go and was it easy for them to separate from you?

Did the nursery have concerns about your child’s behaviour? If yes, please describe

Does your child have friends or do they have difficulties with friendships? Please describe

Sensory Processing

Response to noise:

Is your child distracted by noises easily

Yes

Does your child become stressed by noise / covers ears

Yes

Does your child enjoy loud music or certain sounds

Yes

Response to touch:

Does your child react emotionally or aggressively to touch

Yes

Does your child have difficulty standing in line

Yes

Does your child seem to enjoy physical touch such as often being near peers, or pushing, or rough playing often

Yes

Response to movement:

Does your child often fidget/ bounces/ jumps/ flaps hands and seems to get joy from this

Yes

Does your child often bump into things, leans against surfaces, slouches and may not realise they are doing it

Yes

Is your child cautious with movements – dislikes swings / slides

Yes

Does your child have difficulty climbing stairs

Yes

Response to taste/smell:

Does your child only eat a range of foods that are similar in taste and texture e.g. bland and crunchy

Yes

Does your child avoid certain tastes/ textures/ smells of food

Yes

Does your child prefer foods with bold flavours and textures; has more of an adult pallet

Yes

Response to light:

Does your child enjoy watching things move, or can become fixated on lights

Yes

Does your child avoid bright lights OR can become very distressed in bright light

Yes

Other behaviours:

Does your child run up and down repetitively

Yes

Does your child walk on tiptoes

Yes

Does your child make or blurts out loud noises or hums

Yes

Is your child interested in the texture of materials and toys

Yes

Does your child engage in body-focussed repetitive rubbing / picking skin / pulling hair

Yes

Attention and Activity levels

Does your child blurt out answers / doesn’t wait for a question to be asked

Never

Sometimes

Always

Is your child overbearing and loud when playing with peers

Never

Sometimes

Always

Does your child take actions without thinking of the consequences

Never

Sometimes

Always

Does your child act then instantly says they didn’t mean to

Never

Sometimes

Always

Does your child have difficulty staying on task in the class or in play

Never

Sometimes

Always

Does child your disturb others when playing or working

Never

Sometimes

Always

Does your child make ‘careless mistakes’ or inaccuracies in work

Never

Sometimes

Always

Does your child get out of their seat when not expected

Never

Sometimes

Always

Does your child climb or jump when being still is expected

Never

Sometimes

Always

Does your child fidget and squirm

Never

Sometimes

Always

Does your child always seem ‘on the go’

Never

Sometimes

Always

Does your child have difficulty listening to teaching part of a lesson/ assembly

Never

Sometimes

Always

Does your child avoid or dislike activities which require mental effort

Never

Sometimes

Always

Does your child not finish tasks

Never

Sometimes

Always

Does your child find it difficult to start tasks (even ones they could easily do)

Never

Sometimes

Always

Is your child forgetful during tasks

Never

Sometimes

Always

Does your child often lose items

Never

Sometimes

Always

Does your child struggle to get organised with equipment needed

Never

Sometimes

Always

Can your child manage change? Please describe

Does your child have any fixed routines or ways of doing things that they resist changing? Please describe

Do they have any special interests that take up much of their time? Please describe

Do they have any sensory issues (e.g. avoiding or seeking particular noise, smell, taste, touch, texture)? If yes, please describe

Mental and Emotional Wellbeing

Please tick any concerns you have about your child’s emotional well-being:

Anxiety

Fears or phobias

Obsessive Compulsive Behaviours

Hyperactivity

Hallucinations

School attendance issues

Mood Swings

Eating Disorder

Anger or aggression

Low Mood

Suicidal Ideation

Domestic Violence

Bereavement

Self-Harm

Drug or Alcohol use or addiction

Impulsivity

Short Attention span

Criminal activity/ antisocial behaviours and or Involvement with Youth Offending Team

None of the above

Has your child ever had treatment (including hospitalisation) by, or is currently seeing, a psychiatrist, psychologist, therapist, or counsellor?

Yes

If yes, please give the following details: Nature of the concerns; start and end date of support; where seen and clinician’s name; type of support, for example: counselling, play therapy, cognitive behaviour therapy, group work, family work, parent support and advice.

Previous Assessments

Please indicate if your child has had any of the following assessments? Please share copies of any reports and information on support provided

Paediatric developmental assessment

Educational psychological assessment

Clinical psychological assessment

Speech and language assessment

CAMHS assessment

Occupational Therapy assessment

Children’s Centre

Special Needs Health visitor

Health visitor

Early Years SEN team or Communication and Autism Team (advisory teachers)

SEN Specialist Advice and Support Service

School support including SENCO, TAC (Team Around the Child), parent support, counselling, circle of friends, social support, behaviour support, Pupil Support Base

Social Services including CIN (Child in Need) and CP (Child Protection)

CAMHS Step 2 and Specialist CAMHS

Families First/ Intensive Family Support

Angels/Add-vance/Space/other voluntary agency

None of the above

Other - Please specify (including in the NHS, Independent or charity sector):

If there is anything else you would like to report, in advance of the assessment please outline here:

Please read the following statements and the full cancellation agreements very carefully. Then tick the boxes to show your consent to the following:

I agree for my child to be assessed for Attention Deficit Hyperactivity Disorder (ADHD) by Dr Mairi Emerson-Smith within The Children’s Wellness Centre

I understand that a mental health assessment will be completed as part of my child’s ADHD assessment

I consent and understand that The Children's Wellness Centre will liaise with my child's school regarding this Assessment

I understand that a school observation of my child will be carried out, but to ensure the validity of the results neither myself or my child will be informed of the exact date of this observation

I understand that between booking and the date of the Assessment, if my child is absent from school I must email The Children's Wellness Centre (via the email address hello@childrenswellnesscentre.co.uk) on the morning of the absence, prior to the school day starting, in case the school observation is planned for that day

I am aware that if I do not let The Children's Wellness Centre know of my child’s absence and the Clinician visits the school on that date, there will be an additional fee charged

I understand I can withdraw my consent at any time

I understand that the Clinical Psychologist is unable to edit the results of the Assessment or change observations included in the written report

I understand that a private Assessment does not guarantee a diagnosis, neither does a referral from CAMHS or a GP

I agree to the use of electronic communication. All documents will be password protected and saved as a PDF

I confirm that I have read the Information Sharing Policy and the Confidentiality Policy. I am aware that what we speak about is private, however I understand that there may be times where confidentiality needs to be broken, such as if myself or my child says anything that the team are concerned about in relation to their or someone else’s safety

If you have any questions about the sections on consent or confidentiality, please contact The Children's Wellness Centre.

Terms and Conditions of Therapeutic and Psychological Services within The Children’s Wellness Centre. By ticking the following checkbox, the client is accepting the terms and conditions below:

Our Psychologists will adopt a client-led approach and will offer advice, support and options for next steps, but it is the client’s responsibility to decide what is right for their child

The Psychologist that you are seeing is DBS checked and holds Professional Indemnity insurance, practicing within the framework of their profession and registrations

The Psychologist reserves the right not to accept a referral, terminate an assessment or not to circulate an assessment report if the referral appears to be outside their area of expertise or the client fails to comply with the terms and conditions set out in this agreement

Payment for Assessments is required at the time of booking, in order to secure the space

Payment is usually made via BACS and clients will receive an email invoice once they have booked. Your Assessment is confirmed on receipt of payment

Due to extensive waiting lists, we have a 10 day cancellation or date amendment policy for Assessments, although if some notice is given we will strive to always offer another slot. Late cancellations and missed appointments, will still need to be charged in full

Once payment is received for the Assessment, there will be a 3-day grace period in which the client can cancel the Assessment at no charge (as long as it is within 10 days of the Assessment date). We will begin the process of liaising with the school after this. If the School Observation has been carried out, and the Client decides to cancel after the 3-day grace period and before 10 days prior to the Assessment, the Client will receive a full refund for the Assessment, minus £250 for the time taken to carry out the School Observation. An additional £100 will be deducted from the refund for the administration and screening costs.

For any clients claiming through their health insurance, payment must be settled directly with The Children’s Wellness Centre by the client and can be reclaimed via their insurance provider, using the receipt we can provide

If the client has a complaint against the Psychologist that they are seeing, they must inform The Children’s Wellness Centre, emailing jake@childrenswellnesscentre.co.uk immediately and all efforts will be made to resolve and settle any disputes, without litigation

I can confirm I have read The Children’s Wellness Centre full terms and conditions found at https://childrenswellnesscentre.co.uk/terms-conditions/