Child's name
Date of Birth
School and Year Group
Completed by
Email
Role
How long have you known the child?
When completing this form please be aware for Northumberland CYPS to complete a comprehensive assessment each area of this form needs to be complete in detail giving examples as appropriate.
Academic level and progress
How is the child performing academically (key stage) in comparison to age expectations? Include SATS levels. Please also provide copies of most recent school assessment of attainment / progress
Do you feel the child is reaching their potential? (If not, why not?)
Do they require any support to access the curriculum (SEN register, support in class, ECHP)?
Nonverbal communication
Do you notice any deficits in the child’s nonverbal communication e.g. poorly-integrated verbal and non-verbal communication, to abnormalities in eye contact and body language or posture?
Verbal communication
Language abnormalities e.g. tone of voice, rate or rhythm of speech, volume, stammer, grammatical errors, echolalia (repeating back phrases),
Use of spoken language eg, repetitive language or literal meaning of language, unusual accent difficulty with abstract concepts or sayings, and ability to initiate or sustain conversation interchange or turn taking in conversations.
Communication
Is the child able to have a reciprocal conversation – What does child communication style look like? Can they develop on the topic of conversation Does this need to be scaffolded by another individual?
Is the child able to share interests with peers/ staff Are their interests age appropriate?
Are there any problems in the way the child relates to particular members of staff?
Who usually initiates interaction between the child and the teacher?
Do they have difficulties in building a rapport with the teacher? Do they tell the teacher if they are having difficulties in understanding the work?
Relationship with peers
How does the child get along with their peers?
Do they show any interest in their peer group and in developing same age peer relationships?
Do they have any difficulties in maintaining peer relationships? How do they manage disagreements?
Do they understand how to play reciprocally with other children or work in a group? Can they take turns, join in, follow the rules and understand their role in a game? Are their interactions one-sided or do they reject/ shut down ideas?
Have there been any problems with bullying or teasing to or from the child?
Are they able to manage their own emotions? Do they show sensitivity to the needs or feelings of other children?
Do they share information about themselves and the things that they enjoy socially? E.g. what they did at the weekend or going on holiday or if they were having difficulties at home?
Is the child happier to be with adult or peer support?
Behaviours in school & responses to environment:
How do they respond to unexpected change of teacher? E.g. a supply teacher.
Does the child seek sameness in day to day activities/ environments? Eg, sitting in same seat, following same daily routines, how are they during seasonal festivities
How does the child respond to structured vs. unstructured times of the day? What level of support do they require to achieve this?
Unstructured lessons Including breaks and lunch
Any difficulties noted with transitioning between tasks or lessons?
Have you noticed any unusual behaviours? (e.g. rituals, repetitive movements, unusual mannerisms, quirky and/or idiosyncratic phrases)
Have you noticed any unusual sensory interest/avoidance? Response to sounds, textures, light, sensitivity to textures of food, smell, touching of objects or avoidant behaviours?
Are there any specific difficulties with particular aspects of the environment? (e.g. corridors, dinner halls, assembly, PE)
Inattention, Over activity & Impulsivity - Please provide examples if applicable
Can they start a task independently and can they concentrate enough to finish a task? Do they appear to be listening in class? Are they easily distracted by what’s going on around them? Are they organized and can they plan ahead?
Can the child remain seated? Are they up and down more than other children? Do they fidget or squirm in their seat? Do they rush their work and make careless mistakes? Do they run around excessively when they are not supposed to?
Can they wait and take turns? Do they shout out and blurt out answers? Do they interrupt to a significant degree? Do they talk a lot in class when they are not supposed to? Can they line up appropriately?
Have there been any behavioural problems past or present? If so, how have these been managed?
What are the strengths and challenges in relation to the young person’s behaviours in school?
Have there been any school exclusions or expulsions?
Is there evidence of risky or safeguarding behaviours?
How much does the behaviour you are concerned about affect the child’s quality of life and in what way?
Are you aware that the child has experienced and adverse or traumatic events?
If the referral is accepted, it is expected that the child will be observed in school with parent/carers’ consent. Do you consent to this also?
Name of person completing this form.
Many thanks for taking the time to complete this.
