Name
Virgin Care JADES Referral FormWe require supporting information alongside this referral:Please complete the essential screening tool and include the score belowEssential: M-CHAT Autism questionnaire for under 4 years oldEssential: AQ10 questionnaire for 4 years old + M-CHAT Questionnaire score (under 4 years)………………………….AQ10 Questionnaire score: Child (4-11 years)……………… Adolescent (12-15 years)…………… Adult (16 years +)………………….Desirable: ASQ-SE for pre-school children only (completed by a Health Visitor or Healthy family support worker)ASQ-SE score (for pre-school children only)…………………………Desirable: Any other reports from other professionals involved in child’s careIt is also helpful to have information from more than one person/ setting, eg: parents and Health pleted by:______________________________ Information collated from: ____________________ 1. Child / Young Person InformationSurnameForename/sDate of birthNHS number (if known)Languages spoken Translator RequiredYes / No2. Family / Carer Information Parent/carer nameRelationship to child / young person Contact detailsHome:Mobile:Email:AddressParental responsibilityYes / NoParent/carer nameRelationship to child / young person Contact detailsHome:Mobile:Email:Address (if different from above)Parental responsibilityYes / No3. GP InformationGP nameGP surgery / practice4. Child / Young Person – Nursery / Education SettingConsent to Contact School directly: Has consent from parent / carer been obtained for Virgin Care Ltd to Contact the child’s school directly, in order to obtain information related to this referral and invite them to attend diagnostic clinic?YES / NO 5. Social Care InformationDoes the child / young person have a Child Protection Plan?YES / NOHas the child ever been on a Child in Need or Child Protection Plan?YES / NOIs the child / young person a looked after child?YES / NODoes the family have an allocated social worker?YES / NO Name: 6. Child Medical HistoryDoes the child / young person have existing medical conditions and/or mental health difficulties? YES / NO (If yes, please state)Do they take any medications? YES/NO (If yes, please state)Were there any complications during pregnancy and birth? Were there concerns about the child’s developmental milestones? (e.g. info in parent Red Book)7. Child / Young Person – Family and Social HistoryPlease tell us about anyone in the family who has or is suspected to have learning difficulties, ADHD, mental health difficulties, developmental problems, language problems or autism spectrum disorder. Please tell us about significant or adverse life experiences, which could possibly be relevant to making sense of the child/young person’s emotional wellbeing and behaviour. 8. Reason for referral to JADES:Area of developmentConcerns (Y/N)Please give detailsSpoken language – single words, short phrases, sentences; echolalia; learned language; odd words and phrases; idiosyncratic speech (please give examples)Responding to others – do they respond to their name; do they respond when someone joins them in play. When a conversation is started how do they respond?Interacting with others – do they seek others out, do they start conversations with others? Prefer interacting with adults rather than peers?Eye contact, pointing and other gestures e.g. can they maintain and modulate eye contact with others; vocalizations usually accompanied by subtle changes in gestures, gaze and facial expressions; point to express interest.Play and imagination – please describe how the child/young person plays and what their preferred choices are. Is the play appropriate for their age? Do they have a range of interests? Unusual or restricted interests – Are they fascinated by a particular topic/ item to an intense degree? If yes, please give an example. Are they interested in unusual items e.g. pegs; batteries; stones. Rigid and/or repetitive thinking including routines and rituals – e.g. do they have certain routines and rituals they need to complete; do they say things in the same way and/ or insist others do; do they insist on always following the same route to a destination.Repetitive body movements – e.g. hand flapping; spinning items or themselves; complex mannerisms Over or under reaction to sensory stimuli – Sensory defensiveness e.g.: aversion to loud noises – hoover/ hand dryer; aversion to clothes’ tags. Sensory seeking e.g. looking at light through fingers; playing with water; running sand in fingers. 9. Other current concerns:Area of developmentConcerns (Y/N)Please give detailsEmotional wellbeing/behaviour – Do they know how to emotionally regulate themselves? How do they express their feelings? Attention and concentration – How long can they attend to an activity? Can their attention be shifted to another activity? Motor skills (fine and gross) – Are there any concerns with e.g: walking, running, climbing, holding a pencil/ knife and fork. Learning and memory e.g. are they attaining at school; can they retain information.Eating e.g. aversion to certain foods; restrictive food choices according to colour, texture, brand. Toileting e.g. toilet trained; smearing. Sleeping e.g. difficulties with sleep onset; waking during the night; early rising. Other – any additional information pertinent to the referral. 10. Additional Information:Please tick below any other services who have been involved in the child / young person’s support:AudiologyOpticianHealth VisitorEWMHS (Emotional Wellbeing and Mental Health Service)Educational psychologistSpeech and Language TherapyOccupational TherapyPhysiotherapyPaediatricianSchool nurseChildren’s Learning Disability Service (CLDS)Social ServicesPreschool specialist teacher teamSpecialist teacher team (e.g. behavior support)OtherPlease attach reports and evidence to support referral from the agencies circled above with this referral form. 11. Consent:Consent for Referral:Has consent from parent / carer been obtained for referral? YES / NOConsent to obtain information from other agencies:Has consent from parent / carer been obtained for referral? YES / NOConsent to share information:Has consent from parent / carer been obtained for sharing of information with other professionals? YES / NOConsent to Observe Patient:Has consent from parent / carer been obtained for Virgin Care Ltdstaff to observe the patient in an educational setting? YES / NOParent NameParent signatureDate12. Referrer Information:Name of referrerProfession Contact detailsMobile:Work:Email:AddressSignatureDate of referralThank you for your cooperation, please return to: Virgin Care Single Point of Access, Virgin Care Administration Centre, Kao Park 2, Hockham way, Harlow. CM17 9SR. Or by Email to:VCL.essexwest-harlowcdc@ ................
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