SEN Form

Which form have you been asked to complete?*

Service Request FormASD Pre-assessmentStrengths and Difficulties Questionnaire

Child's Name*

First NameLast Name

Date of Birth*

Date

NHS Number

This can be found on your child's 'Personal child's Health Record - RED BOOK

Address*

House number and street

Town

Post Code

Parent's Name*

First NameLast Name

Parent's Address - If different

House number & street

Street Address Line 2

TownCounty

Post Code

Phone Number for Parent*

Area CodePhone Number

Email*

example@example.com

Any reason to consider urgency? (For any risks of suicidal ideation or self-harm, please ask your child to be referred to CAMHS services without delay by your child’s GP)

Please bullet point the main reasons for referral to our services.

Are there concerns at home, school or in both situations?

How old was your child when you became concerned?

In what way do you hope this assessment will help your child?

FAMILY HISTORY*

	Name of Family Member	Age	Gender	Relationship to child
1
2
3
4
5
6

Does any close family member have the following conditions? If yes, please specify*

Any other significant problem. Please specify.

Developmental Milestones (Please detail if there was any delay or a history of loss of skills)

COMMUNICATION

Please describe any speech or language difficulties that your child is experiencing now or has had in the past.

Please describe your child’s communication. Comment on who they communicate with, how they communicate, why they communicate – for example: to express their needs, to give information, to share experiences, to have a to and fro conversation.

Please describe any difficulties that your child has with listening, responsiveness, understanding what you have said or following instructions.

Does your child have (tick all that applies) and explain in the box below where necessary*

Difficulties understanding humour or sarcasmRepetitive speech (such as repeating words or phrases of others or from TV)Unusual characteristics of their communication such as using an unusual accent, or overly loud or quiet voice or speaking too fast or in an unusual waDifficulties using non-verbal communication effectively such as a lack of facial expression, pointing, waving or gesturing or looking awkward while communicatingLack of, or prolonged, eye contactA lack of responsiveness to their name being spokenNone of the above

SOCIAL INTERACTION

How does your child get on with other members of the family?

How does your child get on with other children/young people?

Does your child (tick all that apply) and explain in the box below where necessary*

Make and maintain friendships?Have any close friendships?Share interest and enjoyment with you or others?Initiate interaction with others?Understand the feelings of other people?Understand how to behave in different situations?Show concern for others who are hurt or upset?Show an awareness of social norms such as not criticising teachers, co-operating with others, showing an interest in current trends?None of the above

PLAY AND IMAGINATION

What does your child like to play with or how do they spend their time?

Does your child show (tick all that applies) and add information in the box below*

Unusual aspects to their play?Lack of pretend play, limited imagination.None of the above

Additional information

Please give details of any intense or unusual interests that your child may have:

Please outline any routines that your child shows a strong preference for or has to follow:

Does your child… (tick if applies and add information the box below)*

Engage in repetitive behaviours or rituals (doing the same thing in a certainway?)Have difficulty with minor changes in routine?None of the above

SENSORY ISSUES

Is your child excessively sensitive to:*

NoiseSmellsThe feel of things such as clothesNone of the above

Does your child show an unusual level of interest in*

Details / Please highlight any sensory seeking or avoidant behaviours that your child displays

MOTOR MANNERISMS (Stimming or repetitive body movements) Does your child (tick all that apply)*

Often walk on their tiptoes or walk in an unusual wayLike to spin themselves around more than other childrenFlap their hands or bounce on their feet when excitedRock themselvesNone of the above

Please outline any repetitive/unusual body movements that your child engages in:

BIRTH DETAILS

Did you have any health problems during your pregnancy?*

Did you take any medication during your pregnancy? (If so, what did you take?) If you didn't take any please state 'none'.*

How long was the pregnancy in weeks (full-term is 37 to 40 weeks).*

What was your child’s birth weight?*

Any history of post-natal depression?*

How was your child delivered and whether they required any after birth care?

Labour and delivery (tick all that apply)*

NormalC-SectionForceps/Ventous

At or after delivery (tick all that apply)*

EARLY DEVELOPMENT

Were any of the following areas of your child’s development of concern to you after birth (tick all that apply)*

Please outline any concerns about early development here

EDUCATION

Name of the preschool/nursery or school attended. Please write home schooled stating the reasons why the child is/was home schooled if applicable. *

Please describe difficulties the child experienced during their preschool, nursery or primary or secondary school years as applicable? (Bullying, running away from school, social isolation, poor school attendance etc.)

Please describe any extra support the child received at preschool nursery, primary or secondary school

Is/was the child Home schooled?*

MENTAL AND EMOTIONAL WELL-BEING

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

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

YesNo

If yes, please give the following details: Nature of the problem; 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, familywork, parent support and advice.

Previous Assessments

Please indicate if your childhas had any of the following assessments? Please attach copies of any reports andinformation on support provided*

Other

SERVICE REQUST FORM

DATA PRIVACY AND INFORMATION SHARING STATEMENT

I confirm that following discussion with school/setting staff, I agree to the involvement of Children’s Services.

I have had the reasons for this service request explained to me, I understand the reasons for the request and understand that my information will be shared with Children’s Services as part of this request. I agree to the request and give consent for Children’s Services to work with my child (or me as the named young person).

I understand that working with my child (or me) will necessitate the sharing of information between relevant services, in the interests of providing a service to me or my child. I understand that the information contained within this form will be recorded on a Hertfordshire County Council case management system and other services may be able to see the content on this form. Hertfordshire County Council is the Data Controller for this information and its lawful basis for processing is to
fulfil its duties in respect of special educational needs provision (public task).

Information on you or your child/young person will be held until 35 years after the date of birth.

Full information on your rights in respect of personal data held about you can be found at https://www.hertfordshire.gov.uk/about-the-council/legal/privacy-policy/privacy-policy.aspx

Please tick the relevant services you do not wish information to be shared with, however please note there may be circumstances where we have to share your details without your consent e.g. if we believe it is the best interests of a child:

Social CareNational Health Services partners (Paediatricians, Speech & Language therapists,CAHMS etc)

CHILD'S NAME*

First NameLast Name

PARENT/CARER NAME*

First NameLast Name

Signature of Parent/Carer*

If the child is under the age of 16 and has not provided a signature, have you sought verbal consent?*

YesNo

If no, please state why:

Strengths and Difficulties Questionnaire

For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain or the item seems daft!

Please give your answers on the basis of the child's behaviour over the last six months.*

	Not True	Somewhat True	Certainly True
Considerate of other people's feelings
Restless, overactive, cannot stay still for long
Often complains of headaches, stomach-aches or sickness
Shares readily with other children (treats, toys, pencils etc.)
Often has temper tantrums or hot tempers
Rather solitary, tends to play alone
Generally obedient, usually does what adults request
Many worries, often seems worried
Helpful if someone is hurt, upset or feeling ill
Constantly fidgeting or squirming
Has at least one good friend
Often fights with other children or bullies them
Often unhappy, down-hearted or tearful
Generally liked by other children
Easily distracted, concentration wanders
Nervous or clingy in new situations, easily loses confidence
Kind to younger children
Often lies or cheats
Picked on or bullied by other children
Often volunteers to help others (parents, teachers, other children)
Thinks things out before acting
Steals from home, school or elsewhere
Gets on better with adults than with other children
Many fears, easily scared
Sees tasks through to the end, good attention span

Do you have any other comments or concerns?

	No	Yes - minor difficulties	Yes - definite difficulties	Yes - severe difficulties
Overall, do you think that your child has difficulties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people?

If you have answered "Yes", please answer the following questions about these difficulties:

	Less than a month	1-5 months	6-12 months	Over a year
How long have these difficulties been present?

	Not at all	Only a little	Quite a lot	A great deal
Do the difficulties upset or distress your child?
Do the difficulties interfere with your child's everyday life in the following 4 areas? Home life
Friendships
Classroom Learning
Leisure Activities
Do the difficulties put a burden on you or the family as a whole?

Name of Parent or Carer

First NameLast Name

Signature