Child ASD booking form | Austism Assessment Centre (AAC)

Child / Young Person's Reference Number (Available from AAC)

Date of Birth

Nursery / School / College Name Where Child / Young Person Enrolled

Year Group

Length of Time / Capacity Known Child

Parent / Carer First Name

Parent / Carer Surname

Parent / Carer Date of Birth

Day

Month

Year

Email - Commissioning Parent / Carer / Person with Responsibility

Phone - Commissioning Parent / Carer / Person with Responsibility

Address - Commissioning Parent / Carer / Person with Responsibility

Occupation / Position of Parent / Carer

Other Person(s) with Legal Responsibility

GP Name and Address

Please list ANY siblings, inc. name, age, relationship, where they live, or other information

Would you like to tell us more about the child / young person's strengths & needs?

Approximately, how long have there been concerns?

Please describe any support or effective strategies currently in place for the child / young person

Please give details about the child / young person's academic ability

Please outline the child / young person's social skills

Communication Skills

Did you (or other people) ever have concerns about the child’s / young person's language development?

Imagination, Rigidity & Plasticity

Routines & Interests

Behavioural Management

Have you been asked to collect the child / young person before the end of school due to their behaviour in class?

Sensory Issues

Motor Skills / Coordination

Mental Health

Please list any other professionals / practitioners involved with the child / young person.

How old was the child / young person when you (or others) first considered that their behaviour might be different from that of most peers?

Have there ever been any child protection issues or have social services ever been involved with the family?

Do you have any current or historic concerns for the child's / young person's safety (any risk indicated - e.g. self harm, suicidal thoughts)?

Has the child / young person been officially excluded from school or been otherwise unable to attend?

Are there any concerns about your housing?

Is there any family history of ASD / ADHD or mental health difficulties? If so, please provide details here

Have there been any upsetting or traumatic physical or emotional events for you and / or your children (e.g. Death, illness, domestic violence, divorce, etc.)

If the child / young person has attended Accident & Emergency, please state the reason for this

Is the child / young person currently taking any medication?

Which prescribed medicines has the child / young person taken in the past and why were they prescribed?

Do you think the child / young person is fit and well at present?

Has your child ever had an assessment for ASD / ADHD before?

Are all parents / carers / those with legal responsibility in agreement that this assessment should be sought?

Parent(s) / carer(s), please indicate on a scale of 1 to 10 how worried you are about the child’s / young person's behaviour at home (1 = not worried, 10 = extremely worried)

Please upload any reports or other assessments relating to the child / young person

You may upload up to 10 supporting documents

Please use this space to provide any other relevant information

By ticking this box, you give consent for this report to be shared with the General Practitioner (GP) stated above.

I agree to The Autism Assessment Centre processing and storing the information submitted in order to respond to my request.

I have read and understood the terms and conditions relating to my booking, and asked for any clarification in advance.

Signed young person (16+)

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Signature of Parent / Carer / Person with legal responsibility

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Name of person completing this form

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