EarlyBird Application Form
EarlyBird is a parent support programme for Suttonfamilies with a child aged 2-5 years with a recent diagnosis of Autism or on a pathway towards an ASD diagnosis. It is a 10 week programme based in the PlayWise hub, for a small group of parents to learn about Autism, behaviours, language and communication play and independent living skills. It is a great opportunity to meet other parents on a similar journey to yourselves and develop a peer support network.
Parent/ carer details
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
County
Post Code
Primary Email
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example@example.com
Primary Contact Number
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Please enter a valid phone number.
Format: 000 000 00 000.
Please let us know which course you have registered your interest for
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Morning, Afternoon, Evening or Online
Child Details
Child's Name
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First Name
Last Name
D.o.B
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Day
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Month
Year
Date Picker Icon
Gender
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Please select
Boy
Girl
Ethnicity
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Please select
1. White British
2. White Irish
3. Gypsy/Roma
4. Traveller of Irish Heritage
5. Any Other White Background
6. Black African
7. Black Caribbean
8. Other Black Background
9. Bangladeshi
10. Indian
11. Pakistani
12. Any Other Asian Backgroun
13. White and Asian
14. White and Black African
15. White and Black Caribbean
16. Any Other Mixed Background
17. Chinese
18. Any Other Ethnic Background
19. Prefer not to say
Home Language
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Nursery/school/childminder's Details
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the child have a diagnosis
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Autism
Awaiting Diagnosis of ASD
Unsure
Description of child’s needs and the impact on the family (or attach a report)
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Please give an approximate date the Diagnosis was given and the name of the paediatrician if applicable
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Sibling Details
If there are more than 3 children, please ask for an extra form
Sibling 1
First Name
Last Name
Date
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Month
-
Day
Year
Date Picker Icon
Gender
Please select
Boy
Girl
Do they have a disability?
Yes
No
Prime area of need
Sibling 2
First Name
Last Name
Date
-
Month
-
Day
Year
Date Picker Icon
Gender
Please select
Boy
Girl
Do they have a disability?
Yes
No
Prime area of need
Sibling 3
First Name
Last Name
Date
-
Month
-
Day
Year
Date Picker Icon
Gender
Please select
Boy
Girl
Do they have a disability?
Yes
No
Prime area of need
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Professionals involved with the family (please give details)
How old was your child when you first had concerns with their development?
What are/ were your concerns with your child's development?
Self Help & Social Skills
Please tell us a little about your child's self help and social interaction strengths and challenges
Does your child wear a nappy at all?
Yes
No
Only at night
Occasionally
Does your child use a toilet or a potty if they can?
Yes
No
Does your child indicate when they need the toilet?
Yes
No
If you answered yes to the previous question, please describe how they indicate when they need the toilet
Dressing Skills
Please describe your child's dressing/ undressing needs
What help does your child need with dressing/ undressing?
Washing/ cleaning skills
Please describe your child's washing cleaning needs
What help does your child need with washing/ bathing/ showering?
Sleeping
Please describe your child's sleep patterns
Does your child sleep well at night?
Yes
No
Varies
Does your child sleep through the night?
Yes
No
Varies
Does your child wake early (before 6am)?
Yes
No
Varies
Are there any particular problems related to bed/sleep that you are concerned about?
Eating
Please describe your child's eating, relationship with food, phobias or obesssions
Will your child sit at a table to eat a meal?
Yes
No
Varies
Will your child feed themselves?
Yes
No
Varies
Are they fussy or particular with foods?
Yes
No
Varies
Are there any particular problems related to food/ eating/not eating that you are concerned about?
Communication - Expressive Language
Please describe your child's use of words/ language
Does your child use any words to communicate their needs?
Yes
No
Inconsistent use of words
If you answered 'Yes', please describe your child's speech/ words
If you answered 'No', please describe how your child communicates
Communication - Understanding of language
Please describe your child's understanding of words/ language
Does your child respond to their own name?
Yes
No
Sometimes
Does your child understand single word instructions/ language?
Would your child fetch an object from another room on request – with or without pointing and/or gestures?
Yes
No
Sometimes
Does your child use any pictures or symbols to help understanding of language??
Yes
No
Sometimes
Behaviour
This section is to understand your child's behaviour
Has your child got any obsessions or attachments to certain objects?
Yes
No
Sometimes
Do they ever display challenging, negative or aggressive behaviours?
Yes
No
Sometimes
Do they tolerate changes of routine - planned or unplanned?
Yes
No
Sometimes
Do they have any fears or dislikes?
Yes
No
Sometimes
Is there anything you can use to motivate your child (something they particularly like e.g. food or activities)?
Yes
No
Sometimes
Would you describe your child as overactive?
Yes
No
Sometimes
Would you describe your child as lethargic?
Yes
No
Sometimes
Are there any areas of your child’s behaviour which are causing you concern?
Yes
No
Sometimes
Please use this space to tell us anything else about your child's behaviour
Play Skills
Please tell us a little about your child's play skills
How would your child occupy themselves if left alone to play?
Does your child ever play imaginatively with dolls, cars etc?
Yes
No
Sometimes
Does your child ever imitate an adult or a child playing?
Yes
No
Sometimes
Does your child ever join in games initiated by others such as ball, peek-a-boo, snap etc.
Yes
No
Sometimes
General Information
Please use this section to tell us ANYTHING about your child you feel is important to know, or something you are particularly worried about.
General Comments......
GDPR Statement
By completing this form, you and your family’s information will be securely stored electronically. This will be accessible to us and other service providers subject to your consent.In order to provide the most appropriate support to you/your family, it may be necessary for us to share some of this information with other support services, for example, Sutton Health Services, NHS Trust teams, Cognus, LB Sutton and other partner agencies. All information supplied is processed and securely stored in accordance with the General Data Protection Regulation, and we will only share the minimum information needed to enable those teams/agencies to provide appropriate support. Your information will be kept for a maximum of seven years unless you revisit or withdraw your consent. You can withdraw you consent at any time by contacting us using the details below. After seven years we will only retain anonymised information i.e. any personal data will be removed so you and your family’s information will not be identifiable. This anonymised information will be used for planning and research purposes to improve services you and other families receive in the future. In certain situations, we may be required by law to share your information to prevent harm to you or members of your family. If there are any concerns about the safety and/or wellbeing of a child/young person/family, local safeguarding procedures will be followed.The information that we hold about families will be used to:Identify families who might be eligible or entitled to additional support from Sutton Council, Sutton Health Services, NHS Trust and other Partners;Carry out other statutory and specific functions related to Child Protection and Safeguarding;Produce statistics for planning and research purposes to assess the performance of our services and inform decisions about current and future service provide. Any statistical data is reported in such a way that individual families cannot be identified – your information is anonymised.
I understand the information recorded on this form will be processed and stored in accordance with the Data Protection Legislation and will be accessible to the above mentioned service providers, and used for the purposes of providing support services to me and my family.
Opt out may affect the level of support we can provide
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Yes
No
I have been informed, understand and agree that some of mine/my family’s information may be shared with other Sutton Council teams, Sutton Health Services, NHS Trust teams and partner agencies for the purpose of providing the most appropriate support for me and my family.
Opt out may affect the level of support we can provide
*
Yes
No
Date
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Day
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Month
Year
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Signature
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