Child's name
Date of Birth
Completed by
Email address
Verbal communication
Have you noticed anything different about your child’s use of language? e.g. tone of voice, rate or rhythm of speech, volume, stammer, grammatical errors, echolalia (repeating back phrases), neologisms (use of made up words).
Use of spoken language - does your child have a tendency to; use the same words or sentences over and over, use or understand words in a literal way, use unusual accents, struggle to take turns in conversations, find it difficult starting conversations or
Non verbal communication
Do you notice any differences in your child’s nonverbal communication E.g. unusual eye contact, body language or facial expressions.
Behaviours at home
What are the strengths and challenges in relation to your child’s behaviours at home?
Is your child generally polite and respectful toward others? Have there been occurrences of swearing, racism or other discriminatory or inappropriate behaviours?
Have there been any behavioural problems past or present? If so, how have these been managed?
Is your child able to show awareness of the rules and boundaries at home?
Is there evidence of behaviours that put them at risk?
Have you noticed any unusual behaviours? (e.g. rituals, repetitive movements, unusual mannerisms, quirky phrases.
Have you noticed any unusual sensory interest or response to sounds, textures, light, sensitivity to textures of food, smell, touching of objects or avoidant behaviours?
Attention, concentration, impulsivity or over-activity
Can they start a task independently and can they concentrate enough to finish a task? Do they appear to be listening when you talk to them? Are they easily distracted by what’s going on around them? Are they organised and can they plan ahead?
Can they wait and take turns? Do they interrupt to a significant degree? Do they talk more than would be expected for their age, are they able to wait in a queue? Are they able to wait their turn?
Can your child remain seated? Are they up and down more than other children? E.g. are they able to watch a film at the cinema.
Relationship with peers
How does your child get along with children of a similar age?
Do they show any interest in developing friendships with children their own age?
Do they have any difficulties in maintaining friendships? How do they manage disagreements?
Do they understand how to play with other children in a group? Are they able to take turns and follow the rules of a game?
Have there been any problems with bullying or teasing to or from the child?
Do they show sensitivity to the needs or feelings of other children?
Relationships with close adults
Are there any problems in the way the child relates to adults?
Do they initiate interaction with adults?
Do they tell adults if they are having difficulties? Would they mention if they were hurt or unwell?
Are they generally interested and motivated to please adults?
How do they respond to unexpected changes? E.g. a different adult picking them up from school than usual.
Do they share information about themselves and the things that they enjoy socially?
How do they respond to boundaries, consequences and to adult authority?
Is the child happier to be with adults or other children?
Response to environment
Does the child prefer unstructured or structured days? How do they respond if plans change or something happens unexpectedly?
How to they behave at home when there are no plans? How do they occupy their time?
Are there any difficulties noted with transitioning between tasks?
Are there any specific difficulties with particular environments? Are there places they do not like to go or love to go?
Are they able to find their way around the local area in a way that would be expected for their age?
Would you ask your child to do a job for you in the house? Housework etc.
How much does the behaviour you are concerned about affect your child’s quality of life and in what way?
Has your child experienced any adverse or traumatic events? E.g. bereavement, abuse, illness, trauma etc.
If this referral is accepted, do you consent for your child to be observed in school as part of the assessment? This is an important part of the assessment, if not please state why.
Name of person completing the form
Thank you for taking the time to complete this form.
