Family History Form Dual -

Dual Family History Form - KENT

Contact

Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10

Child's name

Child's date of birth

Parents/s or carer/s email address

Child's home address

Child's doctor name and address (including postcode)

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 your child typically go to sleep?

What time does your child 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 your child 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

Who has legal responsibility for your child? Please list all parents/carers with this

Please confirm all those with legal responsibility are aware of this assessment, and the appointment date(s)

Yes

Are there any legal custody arrangements we should be aware of?

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:

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 ADHD and Autism assessment at The Children's Wellness Centre, provided by a multidisciplinary team consisting of a Psychologist, Specialist Speech and Language Therapist and Paediatrician

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

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

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

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 part of the Autism Assessment involves a paediatric physical examination, provided by Dr Halbert. I am aware that Dr Halbert is working as an independent practitioner and is responsible for the regulated activity

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. In some cases, if a child is not in school, a QbCheck computer test may be used during the assessment instead

I understand that even with all the information obtained, including the school observation, additional data may be needed to ensure the validity of the final result. In this case, for the benefit of the assessment, my child may be asked during the assessment to take part in a short computer task, called a QbCheck. If this is needed, there will be an additional fee of £85.00 billed after the assessment. To avoid unnecessary fees, the QbCheck is not added to every assessment, as often it is not needed

I am aware that for two parent families, it is best practice for both parents to attend the appointments. For parents who are separated, it is the responsibility of the parent booking the assessment to inform the other of this, as long as both parents share parental responsibility

I understand that the assessment team is unable to edit the results of the assessment or change observations included in the written report

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

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 assessment team 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. We can accept a 25% payment on the day of booking and the remaining 75% can be paid no later than 7 days before the ADHD/Mental Health assessment date

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. If you would like to pay by credit card, please contact the office.

Due to high demand for appointments, if you wish to cancel or change the date of your assessment, we please require 10 days' notice in advance of your first planned appointment

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 £150 will be deducted from the refund for the administration and screening costs

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 office@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 of £250 to re-arrange and travel back to the school on an alternative date

As part of the DUAL assessment process, there are 4 appointments that you are required to attend. If you fail to attend an appointment without providing the required notice, and a new appointment is booked for you, you will be charged a no-show fee of £250. This fee compensates for the time and resources reserved exclusively for your appointment

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/