Name of child
Date of birth
Name of the person completing the form
Contact number of the person completing the form
Relationship to the child
Current concerns
What is your greatest concern for your child at present?
What does your child find most challenging at the moment?
Is your child able to access their learning and participate in school life?
Further Comments
Language development
Does your child have any difficulties with listening and concentrating?
Does your child have any difficulties interacting with other people?
Does your child have any difficulties understanding what people say or following instructions?
Does your child like to chat, listen to others and continue conversation?
Does your child have any difficulties putting sounds, words and sentences together to share information, ideas and wishes?
Does your child understand figures of speech, jokes or teasing?
Further comments
Education
Name of pre-school/school and teacher
If a pre-school age, how many sessions does your child attend? If school age, does your child attend school full time or reduced time-table?
Has the pre-school/school highlighted any concerns to you regarding your child's speech, language, communication skills and interactions with staff or peers?
Further comments
Birth history
Were there any complications during the pregnancy?
Were there any complications during the birth?
Further comments
Milestones and early development
Did you experience any difficulties moving from liquid feeding to solid foods with your child? Does your child have any difficulties with eating or feeding, drinking or swallowing now?
Did you have any concerns about your child's development, for example do you find they are sometimes clumsy or they struggle to pick up objects? Has this persisted e.g. can they ride a bike?
When your child was a baby, did they babble a lot?
When your child was a baby, were they particularly quiet?
How old was your child when they said their first words? The word doesn't have to be said correctly, just that you knew what your child was saying.
Did your child achieve their other developmental milestones (sitting up, crawling, walking, toilet training) within the expected range?
What is your child's ethnic origin?
English, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White background White and Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black, African or Caribbean background Arab Any other ethnic group
What language is spoken at home?
Further comments
Medical history
Has your child had speech and language therapy in the past?
Has your child had any infections / prescribed medication / hospital visits?
Do you have any concerns about your child's hearing or vision at the moment?
Does your child have any other diagnoses?
Further comments
Family history
Who lives at home?
Any family history of speech and language or communication difficulties?
Any family history of ASD or ADHD?
Any significant events affecting your child or family?
Are there any other services or professionals such as Social Care or Health Visitors working with you and your child?
Further comments
Socialisation / play
What does your child enjoy doing at home and how do they spend most of their time? e.g. what play activities do they like, do they like to read, computers, draw - please describe
Does your child have any particular hobbies or interests?
Thinking about early play - does/did your child enjoy interacting with others and taking turns, play imaginative, play independently? What was their favourite toy or object to play with?
Does your child interact with their peers at school/pre-school?
Does your child see friends outside of school (at home or at friend's house)? Do they enjoy parties or after school clubs?
Does your child interact well with siblings and share interest and activities
Further comments
Non-verbal communication
What are your observations about any of your child's non-verbal skills listed below
Pointing - does your child point to what they want, to give you extra clues? Also, do they look in the right place when you point at something?
Facial expression - does your child use a variety of facial expressions and are they able to understand others facial expressions?
Gesture - can your child interpret and understand others' gestures, mannerisms?
Eye contact - does your child make eye contact with most people they meet?
Mannerisms/tics
Further comments
Daily life
Does your child prefer a routine or are they flexible about the days schedule?
If planned events are changed, how does your child react?
How does your child manage change from one activity to another?
Further comments
