Child’s name

/ Gender / DOB / Post code
Name of primary carer: Contact numbers:

Relationship to child or young person:Email address (required):

Address: Parental responsibility?

YesNo

Name of other carer/significant adult: Contact numbers:

Relationship to child or young person:Email address:

Address:Parental responsibility?

YesNo

Siblings:

name: / DOB: / School: / Health?
GP Details:

Child’s ethnicity:

White

/ British /

Asian or Asian British

/ Indian
Irish / Pakistani
Gypsy/Roma / Bangladeshi
Any Other background / Any other Asian background

Mixed

/ White & Black Caribbean / Chinese
White & Black African / Any other ethnic group
White & Black Asian /

Black or Black British

/ Caribbean
Any other background / African
Any other Black background
Adopted / Looked After
Child / EHCP/ Provision agreement / Child Protection Plan / EHAT / Child In Need / Interpreter /Language required
Yes
No
Agency/Service / Already known? Y/N / Consent to
Contact? Y/N / Named professional/ Contact Number
Children’s Disability Service
Speech and Language Therapy
Occupational Therapy
Additional Needs Team
School or College
Hospital Consultant
Educational Psychology Service
Community Paediatrician
Child and Adolescent Mental Health
Barnado’s
Social Care
GP
School Nurse
Language and Social Communication Team (LASC)
Other services

Agenciesinvolve

PARENT/CARER CONSENT FORM FOR THE
ST HELENS NEURODEVELOPMENTAL PATHWAY
FOR MULTI-AGENCY INFORMATION SHARING

Purpose:

The sharing of information between agencies is an important part of the assessment of your child, as it provides a fuller picture of your child’s strengths and needs. Sharing information allows for a range of specialised assessments to be undertaken to help determine the needs of your child.

In order for a full assessment regarding neurodevelopmental differences to be undertaken, several agencies may need to

become involved.

Consent:

We need your consent to share information between agencies. The agencies covered by this consent to information agreement are detailed on Page 2 of the referral form.(Social Care including ICS records)

Child/young person’s name: ______DOB: ______

NHS number: ______

I understand that the information provided on this form will be processed in accordance with the requirements of the 1998 Data Protection Act. It will be treated as confidential and will only be used for purpose of the provision of education and health services. In connection with this purpose, the information may also be processed for the purpose of preventing any fraud or criminal offence to ensure the health, safety and welfare of any child. In pursuit of these legitimate purposes, the information may be shared with other authorities, and with any organisation legitimately investigating allegations of fraud, criminal offences or child protection.

The process has been fully explained to me by the referrer and I understand that there are no set timescales and that each case is individual and will require different services to be involvedincluding those included overleaf and others not stated.

I consent for information sharing between Pathway and the services named overleaf, and for my child to be referred to services that are deemed appropriate by the Pathway, based on my child’s needs.

I understand that the Pathway will refer my child to services that will be of benefit to him/her and these assessments are essential to providing a full and holistic picture of the presentation of my child. By signing this consent I agree, wherever possible, to arrange for my child to attend all appointments sent out and understand that non-attendance can lead to my child being discharged from that service, this will result in an extended waiting time for assessments, and may result in my child being closed to the Pathway.

Should school find that additional support is required in school to help with my child’s access to the curriculum, I consent to a referral to the Language and Social Communication (LASC) Service.

Name of person with parental responsibility: ______

Signed: ______Date: ______

YoungPerson______

Signed: ______Date: ______

St Helens Neurodevelopmental Pathway uses the World Health Organisation, (1992) International classification of diseases: Diagnostic criteria for research (10th edition) (ICD-10), and the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (2013) (DSM V) tools for diagnosing autism spectrum disorder / attention deficit hyperactivity disorder /. As per NICE (National Institute Clinical Excellence) Guidelines (2011), these are nationally recognised tools within the UK for diagnosis of autism spectrum disorder / attention deficit hyperactivity disorder.

Should a diagnosis of any condition be confirmed, mutual agreement of referral to other services to provide post diagnosis support to school / home will be arranged if required.

The consent for St Helens Neurodevelopmental Pathway will apply until your child is closed to this service.

Many thanks for your cooperation.

Parental/carerviews Do you require support completing this form? Y/N ______

(Must be completed by parent / carer)

You may attach additional sheets if necessary.

Please describe current concerns about your child in relation to their:

Social interaction / communication (How they relate to friends / use of non-verbal communication (eye contact / gesture) / language development etc.)

Behaviour (tantrums / play skills / empathy skills / routines / repetitive behaviours etc.)

Attention / concentration / impulse control (energy, organisationand ability to sit and complete tasks)

Sensory differences (smell, clothing, noises etc.)

Please describe your child’s current living circumstances. Any significant life events encountered?

Anything else you would like to tell us?

Brief history of development (age when concerns began / prematurity/ age achieved milestones / speech development / play skills / physical health issues? etc.)

Strengths and interests(what is your child good at?)

What does your child do after school / weekends?

Does your child have peer relationships / friendships? What do they do together?

Referrers concerns (MUST be completed by professional):

Person making the referral Designation andagency

Contact telephonenumber: Email address:

Please describe your concerns regarding this child’s (attach additional sheets if required):

Social interaction (awareness of others / interest in people / seeking comfort /empathy skills /awareness of feelings and emotions / giving comfort / building friendship / turn taking / eye contact / gesture / inappropriate behaviour).

Social communication (use of language for range of functions / topic selection / selection and maintenance of conversation /awareness of listener / vocabulary development / voice control, tone, volume, rate, expression / response to interaction / understanding of complex and non-literal language /understanding of gesture, tone and facial expression.)

Flexibility of thought (pretend play / imagination / need for routine / resistance to change /repetitive or stereotyped behaviour / obsessions or movements / all consuming interests)

Attention, hyperactivity and impulse control (attention and concentration / focus on task / hyperactivity, fidgeting, frequent body movements / forgetfulness / day dreaming / emotional dis-regulation / lack of sense of danger / organisational skills / peer relationships / oppositional behaviour)

Language(level of understanding, speech clarity, expressive language skills, selective mutism, fluency (stammering)).

Physical health (diagnosed conditions, treatment, medications, hospital admissions, impact, sleep)

Learning / development (school performance, attendance, current support etc)

Family circumstances (bereavements, marital breakdown, parental mental health / domestic violence / social care involvement / alcohol / addiction, SEN etc.)

What doyou suspect is the child’s current difficulty? (Please tick)

ADHD / Autism Spectrum Disorder / Attachment difficulties / Global Developmental delay / Speech and language
and
communication / Foetal Alcohol Syndrome

As a referrer I have discussed the following with parents:

  • The Pathway is unable to offer direct support to the parent/ carer/ child. They must be signposted to the appropriate services.
  • If the child’s needs can be met by another service the pathway will end at that point and the case will be closed.
  • If a risk is identified by the referrer this must be managed and referred on to the most appropriate agency to support the child / family.
  • The assessment via the Pathway will determine whether their child meets criteria for a diagnosis of neurodevelopmental disorder eg Autism Spectrum Disorder / ADHD / attachment difficulties etc. Individual agencies will make their own recommendations.
  • I have discussed with parents that the process may take some time and the services to which the Pathway refers usually have waiting lists of their own.

Referral date: Signature:

Referral Application Checklist

Please attach any appropriate reports / assessments in respect of the child/ young person.

The more information you can provide, the more efficient the assessment process

Parent screeningquestionnaire ESSENTIAL 

School screening questionnaire ESSENTIAL 

SNAP IV Forms (ESSENTIAL if ADHD suspected) 

General Development Assessment(Bridge Centre assessments)

GP report (birth and early development history)

Speech and Language Therapist Report

Occupational Therapist Report

Community Paediatrician Assessment

School Nurse or Health Visitor Report

Educational Psychologist Report 

CAMHS / Barnardo’s Report

Coventry Grid (if attachment difficulties suspected)

EHCP / Provision Agreement 

Individual Education/Behaviour Plan (or equivalent) 

EHAT 

Personal Education Plan for LAC Child

Early learning/P-scale Assessments / Besquared 

Y2/6 SAT or CAT results (or equivalent)/ school report

Behaviour Intervention/Youth Offending Team Report

Children’s Social Care

Ensure all relevant reports and screening tools are attached and return to the:

St Helens Neurodevelopmental Pathway

O’Hanlon Centre

Marshall Cross Road

St Helens

Merseyside

WA9 3DE

01744646517

Email:

(Electronic referrals will be accepted ONLY with a signed parent consent form)

Children and young people’s views are veryimportantwhen considering how best to support theminschool. They can be very good at givingadvice.

Please take some time to complete theattachedquestionnaire with the child or youngperson.

You may need to adapt it for younger or less ablechildren.

Children or young person can draw, write, take photos,etc

It is better to write for the child or young person, toenablehim/her to have time to think about theanswers.

Seeing his/her handwriting is not important buthearinghis/her voiceis.

Please take note of any advice the child or youngpersongives you, and incorporate into your planningandmanagement

Please share the child or young person’s views attheplanning and consultation meeting when raisingyourconcerns.

Feel free to use the questionnaire with other childrenforreviews, pupil voiceetc.

1

What makes a good school?

Your views are very important tous!

Name:

Age:

School:

What do you think of yourschool?

How do you feel about getting toschool?

How to make itbetter

How do you feel about teachers inschool?

How to make teachersbetter

How do you feel about break or playtime inschool?

How to make break or playtimebetter

How do you feel about lunch or dinnertime inschool?

How to make lunch or dinnertimebetter

How do you feel about other children inschool?

How to make other childrenbetter

What things do you really likedoing?

What else can we do to helpyou? What are your worries?

How do you feel about answering thequestions?

Thank you!

Child’s name:______DOB:______1