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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?

Yes No Name of other carer/significant adult: Contact numbers: Relationship to child or young person: Email address: Address: Parental responsibility?

Yes No Siblings:

name: DOB: School: Health?

School Details:

GP Details:

ST HELENS NEURODEVELOPMENTAL PATHWAY - REFERRAL FORM for Pathway Admin Office Use Only

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Adopted Looked After Child

EHCP/ Provision agreement

Child Protection Plan

EHAT / Child In Need

Interpreter - Language required

Yes No

Agencies- *By signing the consent form on p3 you agree to us contacting and obtaining information from the below agencies (as required)

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

Agency/Service Already known? 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 – including EHCP advice reports / assessment

Community Paediatrician

Child and Adolescent Mental Health (CAMHS)

Barnado’s

Social Care

GP

School Nurse

Language and Social Communication Team (LASC)

Other services

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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 I am free to commission additional private, specialist assessments and reports but any costs incurred to me will not be

reimbursed by the LA/CCG. I understand that all information supplied by me will be reviewed by the pathway but any diagnosis outlined

may not be accepted, and any recommendations will be considered, but not necessarily accepted. I understand that the pathway only

follows those diagnoses and recommendations made by NHS and Local Authority commissioned services as part of a multi-disciplinary

decision making process.

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 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 involved including 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: ______________________

Young Person____________________________________________________________

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 would 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.

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Parental/carer views 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, organisation and ability to sit and complete tasks) Sensory differences (smell, clothing, noises etc.)

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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?

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Referrers concerns (MUST be completed by professional): Person making the referral Designation and agency

Contact telephone number: 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)).

Address:

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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 do you suspect is the child’s current difficulty? (Please tick)

ADHD Autism Spectrum Disorder

Attachment difficulties

Global Development

al 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. 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:

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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 screening questionnaire 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 Birch Centre

Marshall Cross Road St Helens

Merseyside WA9 3DE

01744 646 517 Email: 5bp-tr.sthelensneuropathway@nhs.net

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

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Children and young people’s views are very important when considering how best to support them in school.

They can be very good at giving advice.

Please take some time to complete the attached questionnaire with the child or young person.

You may need to adapt it for younger or less able children.

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

It is better to write for the child or young person, to enable

him/her to have time to think about the answers.

Seeing his/her, handwriting is not important but hearing his/her, voice is.

Please take note of any advice the child or young person

gives you, and incorporate into your planning and management

Please share the child or young person’s views at the planning and consultation meeting when raising your

concerns.

Feel free to use the questionnaire with other children for reviews, pupil voice etc.

Child’s name: Child’s DOB: 5

What makes a good school? Your views are very important to us!

Name:

Age:

School:

What do you think of your school?

Child’s name: Child’s DOB: 6

How do you feel about getting to school?

How to make it better

How do you feel about teachers in school?

Child’s name: Child’s DOB: 7

How to make teachers better

How do you feel about break or playtime in school?

How to make break or playtime better

How do you feel about lunch or dinnertime in school?

Child’s name: Child’s DOB: 8

How to make lunch or dinnertime better

How do you feel about other children in school?

How to make other children better

What things do you really like doing?

Child’s name:______________________________________ DOB:________________ 1

What else can we do to help you? What are your worries?

How do you feel about answering the questions?

Thank you!