Name



Parents/Carers secondary school aged Questionnaire

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|Child’s name: |Date of Birth: | |

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| |Address: | |

|NHS number: | | |

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|Parents/ Carers names: |Contact number: | |

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|GP: |School or Preschool: | |

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|Date completed: |Email: | |

I agree to information being shared with Health and Education professionals as part of this assessment.

Signed :

Please fill in this form so we can get to know more about your child.

1. What are your concerns (if any) regarding your child? ( include e.g. concerns about communication, behaviour, learning, mental and emotional health, social skills)

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2. What are your child’s strengths?

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3. Is there anything that helps your child? (e.g. preparing them for new places, reward charts, visual calendars and timetables etc).

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4. Which professionals (if any) are currently involved in helping to support your child with their difficulties?

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5. Have there been any Adverse Childhood Experiences (stressful or traumatic experiences that can happen anytime from before birth to present time)?

During pregnancy: Exposure to Alcohol, Drugs, Medication, illness in mother, high stress for mother, Domestic Violence.

After birth: Serious physical illness, and / or Mental Health difficulties in child or close family members, difficulties in family relationships, domestic violence, drug use, changes in family structure, death in family, difficult family circumstances such as asylum seeking, social isolation or poverty, other traumatic events. Have your family received any support from Social Care?

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6. Protective factors. Please describe what’s going well for your child and family? Who are the key supportive and positive relationships in and around the family? What hobbies and interests does your child engage in? What do you enjoy doing together as a family?

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Please use the scoring system below. Do not worry if some of the questions are not relevant for the age of your child. Please mark as n/a (not applicable) if this is the case.

1. No concern This is not true of my child at all

2. Mild concern This is a little true of my child

3. Moderate concern This true of my child

4. Severe concern This is true of my child and is having a big impact

1. Language and Social Communication

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|My child does not point or use other gesture to ask for things | | | | |

|My child does not point or use gesture to show you things | | | | |

|My child finds it difficult to ask for help or expects you to know what they need without telling you | | | | |

|My child doesn’t show pleasure in being with others | | | | |

|My child has difficulties initiating greetings or farewells naturally ie in a way that does not feel learned | | | | |

|My child uses very little gesture to support their communication e.g. waving, nodding/shaking head | | | | |

|My child’s eye contact is different e.g. avoids looking at others, intense stare, gives fleeting looks | | | | |

|You cannot tell how my child is feeling by their facial expressions, or their facial expression may not be appropriate | | | | |

|for the situation | | | | |

|My child finds it hard to read non-verbal communication e.g. tone of voice/facial expression/body language. | | | | |

|My child struggles to have a to and fro conversation with you that builds on your responses | | | | |

|My child’s tone of voice is unusual (e.g. flat/ exaggerated/ babyish/ American accent/mumbled) | | | | |

|My child often appears not to hear or not to listen to others | | | | |

|My child doesn’t get jokes or misinterprets common sayings (such as ‘keep your eyes peeled’) or struggles to use slang | | | | |

|My child may struggle to pick up on subtle aspects of communication e.g. sarcasm | | | | |

|My child will often change the topic of conversation to a favourite topic | | | | |

|My child does not appear interested in what others have to say | | | | |

|My child finds it hard to tell you about their day when you ask | | | | |

|My child has difficulty with the concept of time | | | | |

|Please add any other comments about your child’s language/ communication and give examples: |

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2. Relationships and Friendships

1. No concern This is not true of my child at all

2. Mild concern This is a little true of my child

3. Moderate concern This true of my child

4. Severe concern This is true of my child and is having a big impact

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|My child is reluctant to let others join in with their play/ take turns | | | | |

|My child prefers the company of adults | | | | |

|My child didn’t seek comfort when they had hurt themselves when they were younger | | | | |

|My child gets on better with children who are either older or younger | | | | |

|My child tends to be solitary and not seek to meet up with friends | | | | |

|My child had difficulties with play dates and friendships when they were younger | | | | |

|My child is interested in group games but wants to play by their own rules | | | | |

|My child has one or two intense friendships and finds it hard to ‘share’ their friends | | | | |

|My child has difficulty interpreting social cues e.g. over familiar to strangers or people in authority | | | | |

|My child can make comments about people which are socially inappropriate e.g. “they smell funny” | | | | |

|My child does not pick up on how other people are feeling e.g. bored/not interested/annoyed | | | | |

|My child may misread social situations (e.g. being bumped into may mean being attacked, or when others don’t do things | | | | |

|their way, they feel rejected or bullied.) | | | | |

|My child finds it hard to understand others’ perspectives or views | | | | |

|My child was late to develop symbolic or pretend play (didn’t participate in role play) | | | | |

|My child finds it hard to engage with imaginative activities including creative writing, understanding why characters | | | | |

|behave in a certain way in literature, or history | | | | |

|Please add any other comments made about your child’s friendships and give examples: |

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3. Stereotyped or Repetitive Behaviour Speech/Motor Movements

1. No concern This is not true of my child at all

2. Mild concern This is a little true of my child

3. Moderate concern This true of my child

4. Severe concern This is true of my child and is having a big impact

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|My child’s speech can sound formal or grown-up | | | | |

|My child uses unusual words e.g. made up words | | | | |

|My child often echoes words or phrases they have heard | | | | |

|My child memorises and repeats chunks of conversation heard in DVDs/Books or on television | | | | |

|My child will make repetitive noises e.g. humming, growling, squeaking | | | | |

|My child displays repetitive hand and/or body movements e.g. hand flapping, twisting, wringing, rocking, maybe at times | | | | |

|of excitement, distress or anxiety | | | | |

|My child walks awkwardly | | | | |

|My child lines up toys or arranges objects or did this when younger | | | | |

|My child engages in repetitive behaviours e.g. opening and closing doors, turning lights on and off, filling and | | | | |

|emptying containers. | | | | |

|Please add any examples: |

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4. Routines and Rituals

1. No concern This is not true of my child at all

2. Mild concern This is a little true of my child

3. Moderate concern This true of my child

4. Severe concern This is true of my child and is having a big impact

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|My child has specific routines and rituals e.g. .something has to be done in exactly the same way | | | | |

|My child is upset by changes to routines or environment e.g. teacher off sick/road closed | | | | |

|My child finds it difficult to move from one activity/room/environment to another very difficult e.g. transitions | | | | |

|My child often asks the same question repetitively and wants you to answer them in a particular way | | | | |

|My child sticks to rules and expects others to as well | | | | |

|Please add any examples: |

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5. Interests

1. No concern This is not true of my child at all

2. Mild concern This is a little true of my child

3. Moderate concern This true of my child

4. Severe concern This is true of my child and is having a big impact

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|My child’s interests change over time but are always intense to the exclusion of other activities | | | | |

|My child has interests that preoccupy her/him and that might seem unusual to other people e.g. traffic | | | | |

|lights/timetables | | | | |

|My child has special interests that seem unusual in their intensity but are otherwise appropriate for his/her age | | | | |

|My child accumulates facts on certain subjects but does not really understand their meaning or has collections of | | | | |

|objects | | | | |

|My child has unusual fears / phobias | | | | |

|Please add any examples: |

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6. Sensory

1. No concern This is not true of my child at all

2. Mild concern This is a little true of my child

3. Moderate concern This true of my child

4. Severe concern This is true of my child and is having a big impact

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|My child is distressed by loud or unusual noises, may cover ears to block out sound | | | | |

|My child is sensitive to the feel of certain clothes (including labels and seams) | | | | |

|My child has an unusual reaction to pain or temperature | | | | |

|My child has a limited diet and/or only likes certain foods due to colour/ texture etc | | | | |

|My child does not like food to be touching on their plate | | | | |

|Please add any examples: |

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7. Please comment on concentration and attention, distractibility and impulsivity.

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8. Please also complete the following section:

Compared with other children their age, does your child have difficulty with any of the following areas? (please tick and comment):

| |ACTIVITY: |No |A little |A lot |Comments: (e.g. How? What? When? etc.) |

| | | | | |(List any strategies used) |

|1 |Self care: |

|a |Dressing and undressing | | | | |

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|b |Feeding | | | | |

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|c |Toileting | | | | |

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|d |Bathing | | | | |

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|Compared with other children their age, does your child have difficulty with any of the following areas? (please tick and comment): |

| |ACTIVITY: |No |A little |A lot |Comments: (e.g. How? What? When? etc.) |

| | | | | |(List any strategies used) |

|2 |Classroom skills: |

|a |Using a pencil | | | | |

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|b |Drawing and Writing | | | | |

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|c |Using scissors | | | | |

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|3 |Gross motor activities: |

|a |Balance | | | | |

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|b |Co-ordination – jumping , hopping, skipping | | | | |

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|c |Muscle strength and endurance, i.e. tires easily | | | | |

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|d |Joint hypermobility, i.e. very flexible | | | | |

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|e |PE activities | | | | |

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| |ACTIVITY: |No |A little |A lot |Comments: (e.g. How? What? When? etc.) |

| | | | | |(List any strategies used) |

|f |Riding a bike |  |  |  | |

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|g |Swimming |  |  |  | |

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Return to: Add Service Address

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Community Children’s Health Partnership

| Autism Spectrum Disorder Team |

|Throgmorton House |

|10a Throgmorton Road |

|Knowle |

|Bristol |

|BS4 1HR |

|Telephone: 0300 1256 206/7 |

|e-mail: sirona.asdcchpcoordinators@ |

|Website: cchp.nhs.uk |

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