ASD Family History Form -

Family History Form

Prior to completing this form, please review our policies, which can be found here.

ASD Family History Form - KENT new (from 3rd July 2025)

Updates

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Demographics

Child's name

Child's date of birth

Name of parent/s or carer/s

Ages of parent(s) / carer(s)

Occupations of parent(s) / carer(s)

Who holds parental responsibility?

Name of the person(s) completing the form and the relationship to the child

Parents/s or carer/s email address

Contact telephone number

Child's home address

Child's Doctor and Practice address

Please provide the name of the school your child attends, and the current year they are in

Family

Who lives at home? (Please include ages of any other children, whether they are full or half-siblings, step-siblings or adopted siblings)

Please list any other siblings or half-siblings who do not live in the family home

Please give details of any diagnosed or suspected neurodevelopmental differences, mental health difficulties, learning difficulties or physical health conditions in any blood relatives of the child.

How things are currently

Please briefly describe your main reasons for concerns regarding your child. (We will explore these together in detail during the assessment.)

How long have these difficulties been present and do they interfere with your child’s daily functioning? Please describe.

How old was your child when you thought their development or behaviour were different from that of other children? What did you notice?

Did you speak to a professional about your concerns? If yes, what type of professional did you speak to and what advice were you given?

Who do you draw upon for support as a family (e.g. extended family, outside agencies, close friends)?

Have you ever received support from social services or had a social worker? What was the reason for the referral? What support did they provide? Was it helpful?

Does your child have any physical or mental health diagnoses?

Does your child have any specific learning difficulties / disabilities?

Has your child ever had any serious illnesses or accidents/injuries?

Has your child experienced any significant life events or trauma? If yes, please describe.

How would you describe your child’s current bedtime and sleep pattern? What time do they go to bed and wake up? Are they difficult to wake? Do they appear tired during the day?

How are things at nursery / school currently?

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

Has your child ever been officially excluded from school?

How are things at home?

Does your child have danger stranger awareness?

Do you feel your child might be particularly socially vulnerable amongst their mainstream peers?

Do you notice your child feeling excessively worried, sad, nervous, reserved, isolated, uninterested to engage in activities that used to bring them pleasure, appearing in stronger need of your support than is usual for them?

Does your child cope with difficult emotions by engaging in challenging behaviours such as verbal / physical aggression, disobeying rules, throwing objects, slamming doors, destroying property, harming animals, themselves or others?

Is there anything that makes you particularly worried about your child?

What does your child least enjoy doing?

What are your child’s particular strengths and hobbies?

Neurodevelopmental Profile

When can you remember your child first smiling at you?

As a young child, what games did your child enjoy playing? If I looked through a window at your child playing those games by themselves, what would I see?

And what would I see if your child was playing those games with other children their age back when they were around 4-5?

If I looked through a window at your child now, at their current age, amongst a group of other children of various ages, what would I see?

Does your child have friends? Please describe.

What does your child think about changes and transitions?

Does your child have any strong preferences to do things in a very particular way or in a fixed routine?

Do they have any special interests that take up much of their time? Do they talk about anything particular all the time?

How well is your child able to focus, pay attention and concentrate on one activity? Please try to give an estimate in minutes. If this varies between activities, please give detail.

How well is your child able to remember two- and three-step instructions?

Do they experience restlessness or appear to be driven by a motor?

Are they “think before you act” or “act before you think” kind of person?

Do they have any sensory sensitivities, for example, do they avoid or seek out a particular sensation, smell, noise, taste, touch, texture?

Does your child enjoy big body movements or being upside down?

Does your child tend to tiptoe, spin or engage in any unusual ways of moving their body?

Has there ever been a regression (loss) of skills that your child had previously learnt?

Pregnancy, Birth and Post-Partum

Is the child an adopted child? (If yes, please answer however many of below you can to the best of your knowledge.)

How did the pregnancy go? Were there any complications?

Was the pregnancy full term?

Any medication during pregnancy?

Number of cigarettes smoked daily during pregnancy?

Alcohol consumption per day during pregnancy?

Any illegal substances during pregnancy?

How did the birth go? Was there any assistance required?

Did your baby need any support breathing or special care after being born?

Child’s weight at birth

If you gave birth, how were you in yourself in the early weeks / months after your baby arrived?

How did the main caregivers bond with their new baby?

Was this your first baby?

Early Development

Were there any concerns that your child was developing slowly?

How old was your child when they first walked unaided?

How old was your child when they started using single words (other than mum and dad)?

How old was your child when they started using two or three word phrases?

Has your child ever been referred to speech and language services?

Did you have any difficulty with potty training your child?

At what age did your child acquire bladder control by day (i.e. stop having accidents)?

At what age did your child acquire bladder control at night (i.e. stop having accidents)?

At what age did your child acquire full bowel control (i.e. stop having accidents)?

Have there been any particular difficulties with the following: tying shoelaces, doing up buttons, handwriting, riding a bike, using playgrounds, using a knife and fork properly? Please describe:

Were there any problems with sleeping, feeding, crying or any other problems as a baby?

Did your child settle into a good routine as a baby? Please describe in more detail.

Was your child an “easy cuddly” baby?

Was your child as a baby happy to separate from you / happy to be put down?

Did your child go to playgroup or nursery school? If yes, at what age did they go and was it easy for them to separate from you?

Did the nursery have concerns about your child’s development or behaviour? If yes, please describe.

How did transition to primary school(s) go? (If applicable, please also describe transition to secondary school and how your child settled in.)

Is there anything else you would like to report in advance of the assessment?

Please read the following statements and the full cancellation agreements very carefully, as these explain the processes of the full assessment even further.

Please then tick the boxes to show your consent to the following:

I consent for my child to attend an Autism assessment at The Children's Wellness Centre, provided by a multidisciplinary team, consisting of a Psychologist, Specialist Speech and Language Therapist and Paediatrician

I am aware that the Psychologist will be acting as the lead professional throughout my child's Autism assessment, and will liaise with the other team members in order to determine the final outcome

I understand I can withdraw my consent at any time, although withdrawal of consent will not necessarily be reflected in the fees due

I am aware that the Autism assessment is a 2-step process, and only completing both steps of this process will ensure the full assessment, in line with guidance has been carried out. I am aware I do not have to attend Step 2, if my child does not meet the threshold for a potential diagnosis, after Step 1

I understand that a mental health assessment, including Autism screening, will be completed as part of Step 1 of my child’s assessment. I am aware I will be provided with feedback after this assessment has taken place, and it is then at my discretion whether I continue with the next phase (Step 2) of the assessment process

I understand that once I have been given feedback in relation to my child's initial mental health assessment (Step 1) I have 2 weeks to book in and pay for Step 2; the full Autism assessment process

I am aware that if I choose to wait longer than this timeframe, to progress from Step 1 to Step 2 of the Autism assessment, I may have to pay for another mental health assessment for my child. I understand it is very important for the process that the Psychologist (the lead professional) has the most up to date information about my child and this is why this timeframe is fundamental

I am aware that if I choose to progress onto Step 2 of the assessment, a medical examination will take place by Dr Jay Halbert. I understand that Dr Jay Halbert is providing treatment as an individual provider and that he has full responsibility for carrying out the regulated activity

I consent and understand that The Children's Wellness Centre will liaise with my child's school regarding this assessment

I understand that in very rare cases, where the results are inconclusive, a school observation may need to be carried out, which will incur additional charges. This will be discussed with me, if appropriate

I am aware that for two parent families, it is best practice for both parents to attend the appointments

I understand that the Clinicians are unable to edit the results of the assessment or change observations included in the written report

I understand that a private assessment does not guarantee a diagnosis, neither does a referral from CAMHS or a GP

I understand that all paperwork and notes are owned and securely stored by the individual Clinicians carrying out each appointment, in accordance with GDPR. Consultation reports and letters are not stored internally by The Children's Wellness Centre

I agree to the use of electronic communication. All documents will be password protected and saved as a PDF

If appropriate I agree for any relevant information about my child to be shared between relevant professionals (e.g. school, doctor, psychologist, NHS therapist etc) in confidence, in the best interest of the child's development (this will be discussed with parents first)

If you have any questions about the sections on consent or confidentiality, please contact The Children's Wellness Centre.

Terms and Conditions of Therapeutic and Psychological Services within The Children’s Wellness Centre. By ticking the following checkbox, the client is accepting the terms and conditions below:

Our Clinicians will adopt a client-led approach and will offer advice, support and options for next steps, but it is the client’s responsibility to decide what is right for their child

The Clinicians that you are seeing are DBS checked and hold Professional Indemnity insurance, practicing within the framework of their profession and registrations

The assessment team reserves the right not to accept a referral, terminate an assessment or not to circulate an assessment report if the referral appears to be outside their area of expertise or the client fails to comply with the terms and conditions set out in this agreement

Payment for assessments is required at the time of booking, in order to secure the space. For Step 1 of the process, we can accept a 50% payment at the time of booking and the remaining 50% can be paid no later than 7 days before the assessment date. For Step 2. the final phase of the assessment, this payment is due in full at the time of booking, in order to confirm the next set of appointments

Payment is made via bank transfer and clients will receive an email invoice once they have booked. Your assessment is confirmed on receipt of payment

Due to high demand for appointments, if you wish to cancel or change the date of your assessment, we please require 10 days' notice.

Once the initial Step 1 assessment has been booked, there will be a 3-day grace period in which the client can cancel the assessment at no charge. After this, we will begin the process of liaising with the school and organising all paperwork. If the assessment is cancelled with 10 or more days notice, clients will receive a refund of their fees paid, however a £150 fee will be deducted from the refund to cover the cost of administration and screening costs

As part of the Step 2 process, there are 3 further appointments that you are required to attend. If you fail to attend an appointment, without providing the required notice, and a new appointment is booked for you, you will be charged a no show fee of £250. This fee compensates for the time and resources reserved exclusively for your appointment

For any clients claiming through their health insurance, payment must be settled directly with The Children’s Wellness Centre by the client and can strive to be reclaimed via their insurance provider, using the receipt we can provide

Our complaints policy can be accessed at the footer of our website. If the client has a complaint against a Clinician that they are seeing, they must inform The Children’s Wellness Centre, emailing jake@childrenswellnesscentre.co.uk immediately and all efforts will be made to resolve and settle any disputes, without litigation

I confirm I have read The Children's Wellness Centre policies (Privacy, Information Sharing, Confidentiality, Complaints, Zero Tolerance, Covid-19 and Illness policies), accessed via the policies page

I can confirm I have read The Children’s Wellness Centre full terms and conditions found at https://www.childrenswellnesscentre.co.uk/terms-conditions/