1. Background Information, Family and Medical History
Client name
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Please enter the client's date of birth
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Day
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Month
Year
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Name of parent / carer where appropriate
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Please give a brief overview of the reasons why you have sought out an assessment of ASD
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How old was the client when differences in their development/interactions/behaviour were first noted?
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Family and medical history
Who does the client live with?
Do any immediate or wider family members have a diagnosis of autism or ADHD or experience significant mental health difficulties? (please give details if you are comfortable doing so)
Has the client experienced any physical health difficulties (including hearing or vision concerns), had any hospital admissions, or had the need to take any ongoing medications?
Has the client experienced any mental health difficulties?
Has the client experienced any adverse/traumatic childhood events?
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2. Early Development (0-3 years old)
Please answer the following questions in relation to this time period only (we appreciate that it may be more difficult to remember if you are responding about a teenager or an adult!). There will be other opportunities to discuss different developmental stages etc in the interview itself
Were any complications experienced during pregnancy with the client or at the time of birth ? At how many weeks was the client born, and what did they weigh?
Were there any concerns about the client as a baby (feeding, comforting, settling to sleep etc.
At what age did the client start to crawl?
And Walk?
At what age did the client start to use single words
...and speak in phrases?
Were there any early concerns in regard to the client's early communication? (smiling/making eye contact/pronouncing words/making their needs known etc)
Were there any concerns in regard to the client achieving toileting independence during the day or night?
Did the client ever have a regression in skills? (e.g starting to talk and then no longer talking for some time)
What did the client enjoy playing with or doing as a toddler?
How did the client respond to wider family members or other adults during their toddler years?
How did the client cope with changes to routine as a toddler?
Were any sensory sensitivities or sensory seeking behaviours noted?
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3. Education and other settings outside of the home
ASD is a pervasive disorder, and as such it should be evident in multiple settings. We would be grateful for any information you can provide about these settings
Did the client attend any toddler groups? How did they respond to these?
Did the client attend a nursery/pre-school setting? Please give details
Were any concerns noted by parents or staff during these years? (e.g separation from parents/communication/interactions with peers/interests)
Were any concerns noted by parents or staff when the client started Reception and continued through school?
Has the client ever accessed input from professionals (Speech and Language Therapist, Educational Psychologist, Occupational Therapist etc.)
During the client’s early years, were any concerns noted when visiting others or visiting places?
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4. Strengths and resilience factors
Thank you for completing this form, it gives us a really solid basis for the interview-based developmental history. Assessments like these can sometimes focus too much on issues and worries, and not enough on the positives. We would be really interested to hear whatever you can tell us about the client's positive qualities, achievements, and the things that help them to manage the day to day demands of life
What are the client’s strengths/positive attributes/skills and talents?
How does the client manage everyday demands in terms of coping strategies and skills?
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