ADHD/ASC Registration Form for Children/Adolescents

ADHD/ASC Registration Form for Children/Adolescents

This form is to be completed by a parent, with the child being assessed in mind.
We are pleased you have decided to take this step in seeking a Neurodevelopmental assessment for your child. We believe that early intervention and the right support strategies make an enormous difference to a child's development.

The questions below are designed to provide us with important information about your child. Some questions may bring up some emotions, and some may not feel relevant to your child. That is okay.

We ask for brief descriptions in these questions, and will go through relevant answers in more detail in the assessment process.

If there are any questions you are unsure of, please contact us on info@dianneeveritt.com, and we will be happy to guide you.
Child/Adolescent's Details
Full Name of child/adolescent (person being assessed)*

First NameLast NameInitials
Child's Date of Birth*

MonthDayYear
Date
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Academic Year
Name of Current School
Please list previous School's attended, starting from Reception Year
GP Details

Name of GP

Name of GP Surgery

Contact NumberAddress of Surgery

Contact number for GP
Parent Details
Your Name*

First NameLast Name
Relationship to patient*
Your Phone Number*

Country CodePhone Number
Your E-mail*
example@example.com
Method of funding*
Bupa Pre-authorization code, if applicable
How did you hear about us?*
Developmental History
Were there any complications in pregnancy? If so, please specify.
Did the mother of the person being assessed smoke cigarettes, drink alcohol, or use narcotic drugs during pregnancy?
How far along was the pregnancy when they were born?
Was it a normal vaginal delivery or a caesarian section?

Normal Vaginal DeliveryVaginal Delivery with ForcepsPlanned Caesarian SectionEmergency Caesarian
Were there any complications at birth? If so, please specify
Were they a settled, calm baby, or did they cry a lot?
Could they be comforted easily when upset as a baby and toddler?
Please state at what age you met the below developmental miestones?
Sitting
Crawling
Walking
First Words
Two-word sentences
Full sentences
Potty trained
Do you have any concerns, or notice anything unusual about them?
Did/do they have any special interests as a child? If so, please specify
Are they good at remembering and noticing details that others typically don't? For example, specific dates, birthdays, types of aeroplanes etc?
Was there any significant trauma or disruptive life events during childhood, such as divorce, immigration, parent with a health condition etc?
Do they eat a wide variety of foods and textures? How was this when they were younger? Please elaborate.
Are/were there any sensory sensitivities? For example, wanting a lot of close physical contact or avoiding physical contact, difficulties with labels or textures of clothing, painful hair brushing, not liking different textures etc?
Did they develop skills to be independent at an appropriate time (e.g. getting themselves ready in the morning, packing their school bag, getting to school)?
Social Development
How would you describe their social interactions? (Choose all the apply)

Preferred to play aloneDifficulty making friendsHad many friendsSocial and outgoingOther (please specify below)
If other, please specify
How would you describe their temperament? (Easy going, sensitive, shy etc?)
How do they respond to new people?
Did they avoid eye contact?

YesNoSometimesCan't remember
How you generally describe them?
How do they respond to unexpected changes or sudden changes to plans or routine?
Did they have a tendency to take things very literally/at face value? (For example, struggling to read the subtext of a conversation or missing sarcasm?)
Are they so detail-oriented that they can tend to miss the bigger picture?
Educational History
How did they adjust to starting Reception?
How did they do in Infant/Junior School?
How did they transition to Secondary School, if applicable?
Have they in the past or do they currently have any difficulties at school?
Have they received remedial or learning support at school?
Were they ever formally assessed for any developmental or learning difficulties?
What has the feedback from teachers been about them?
Do you think they are meeting their full potential at school?

Meeting their full potentialSometimes meets their full potentialIs capable of achieving moreSignificantly underperforming
Have they had any behavioural difficulties at school?
Were there any of the following difficulties? (tick all the apply)

ReadingWritingTimes TablesHomeworkForgetfulHyperactiveFidgetingConcentration
Do they ever lose things and are they forgetful?
Family History
Has anyone in the family ever been diagnosed with any of the following?

AutismADHDDyslexiaDyscalculiaDysgraphiaDyspraxiaTourettesLearning difficultyAny other neurological condition
Medical History
Have there been any significant medical conditions or illnesses?
Have they ever had a head injury or concussion? If so, please elaborate
Have they ever struggle with tics, or repetitive movements?
Terms and Conditions
Please read our terms and conditions. Our full terms and conditions can be found here. By checking the boxes below, you acknowledge that you have read the terms and conditions, and agree to them whilst working with any of the Clinical or Counseling Psychologists at Dianne Everitt and Associates.

Please take particular note of the following in realtion to fees and cancellation of sessions.

Cancellation Policy

As appointments for ADHD and Autism assessments last a number of hours, this is a significant amount of time that our Psychologists allocate to the assessment. These appointments are carefully planned and allocated, and we appreciate as much notice as possible should any changes be needed.

If you cancel the assessment within 48 hours, you will be charged £300.

If you reschedule with less than 48 hours notice, you will be charged £100.

If you fail to cancel the appointment, you will be charged £300.

Settlement of Fees

You will be liable for the settlement of fees, which can be paid by bank transfer following the receipt of an invoice.

If you are using insurance to cover the cost of your sessions, please note that you need to obtain preauthorization before the first appointment, and there may be an excess for you to cover, depending on your policy. If your insurance does not cover the assessment fee in part or in full, you will be liable for the fee.
Acceptance of Terms and Conditions*

I acknowledge that I have read the full terms and conditions, and agree to themI accept the cancellation policyI accept responsibility for the settlement of fees, and will be liable if my Insurance does not cover it
Should be Empty:

ADHD/ASC Registration Form for Children/Adolescents

Child/Adolescent's Details

Parent Details

Developmental History

Social Development

Educational History

Family History

Medical History

Terms and Conditions