ASD Family History Form -

Family History Form

Prior to completing this form, please review our policies, which can be found here.

ASD Family History Form - LONDON

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Child's name

Child's date of birth

Parents/s or carer/s email address

Contact number

Child's home address

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 does (s)he typically go to sleep?

What time does (s)he 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

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

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 does (s)he 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)

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

Preferred day for feedback call

Monday

Tuesday

Wednesday

Thursday

Friday

Weekend

Preferred time for feedback call

Morning

Afternoon

Evening

Please confirm the best contact number for the feedback call

Please read the following statements and the full cancellation agreements very carefully, as these explain the processes of the full assessment even further.

Please then tick the boxes to show your consent to the following:

I consent for my child to attend an Autism assessment at The Children's Wellness Centre, provided by a multidisciplinary team of a Clinical Psychologist, Specialist Speech and Language Therapist and Paediatrician

I am aware that the Clinical Psychologist will be acting as the lead professional throughout my child's Autism assessment, and will liaise with the other team members in order to determine the final outcome

I understand I can withdraw my consent at any time, although withdrawal of consent will not necessarily be reflected in the fees due

I am aware that the Autism assessment is a 2-step process, and only completing both steps of this process will ensure the full assessment, in line with guidance has been carried out. I am aware I do not have to attend Step 2, if my child does not meet the threshold for a potential diagnosis, after Step 1

I understand that a mental health assessment, including Autism screening, will be completed as part of Step 1 of my child’s assessment. I am aware I will be provided with feedback after this assessment has taken place, and it is then at my discretion whether I continue with the next phase (Step 2) of the assessment process

I understand that once I have been given feedback in relation to my child's initial mental health assessment (Step 1) I have 6 weeks to book in and pay for Step 2; the full Autism assessment process

I am aware that if I choose to wait longer than this timeframe, to progress from Step 1 to Step 2 of the Autism assessment, I may have to pay for another mental health assessment for my child. I understand it is very important for the process that the Clinical Psychologist (the lead professional) has the most up to date information about my child and this is why this timeframe is fundamental

I am aware that Step 2 of the Autism Assessment involves a paediatric physical examination, provided by Dr Gray or Dr Burmester at the Chiswick Medical Centre, Bond House, 347-353 Chiswick High Road. I am aware that information and client data will be shared between The Children's Wellness Centre and Dr Gray and Dr Burmester's medical clinic/Chiswick Medical Centre

I understand that Dr Gray and Dr Burmester's clinic partners with The Children's Wellness Centre to provide this part of the assessment, in line with NICE guidance, however I am aware that the Chiswick Medical Centre is a separate entity to The Children's Wellness Centre and may have their own terms and conditions in relation to cancellations

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

I understand that in very rare cases, where the results are inconclusive, a school observation may need to be carried out, which will incur additional charges. This will be discussed with me, if appropriate

I am aware that for two parent families, it is best practice for both parents to attend the appointments

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 all of The Children's Wellness Centre's Policies. 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 Clinicians 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 Clinicians that you are seeing are DBS checked and hold 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. For Step 1 of the process, we can accept a 50% payment on the day of booking and the remaining 50% can be paid no later than 7 days before the assessment date. For Step 2. the final phase of the assessment, this payment is due in full at the time of booking, in order to confirm the next set of appointments

Payment is made via bank transfer 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

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

Our complaints policy can be accessed at the footer of our website. If the client has a complaint against a Clinician 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 confirm I have read The Children's Wellness Centre policies (Privacy, Information Sharing, Confidentiality, Complaints, Zero Tolerance, Covid-19 and Illness policies), accessed via the policies page

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

Family History Form

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