Background Information Form Subscribe Basic InformationEnsuring SafetyPregnancy and Birth HistoryMedical InformationFamily HistoryOther ProfessionalsEarly Years and Child DevelopmentHome and Family LifeEducationStrengths and Interests"A day in the life" Caregiver Questionnaire"Hopes and Dreams" Caregiver Questionnaire Please complete this form as fully as possible to help inform your Young Person’s therapy provision. We recognise that this form is extensive; this is so that we can gather the relevant information that we require to provide services for your Young Person, and we thank you for your time and attention in advance. If you require any support with this task, please don’t hesitate to contact us, we are happy to help. Once returned, we will triage the form prior to adding your Young Person to the relevant therapist’s waiting list. PLEASE NOTE: If you close the browser window your results will be saved as long as you return to this page using the same device. If, for any reason, your original responses do not reappear, please immediately email office@helpingkidsshine.co.uk.Basic InformationYoung Person's First NameYoung Person's Middle Name(s) (if any)Young Person's Last NameYoung Person's Date of BirthCaregiver's First NameCaregiver's Last NamePlease provide your email address. Please note that a copy of your responses will be emailed to this address. You are responsible for ensuring that the email address is correct.How would you like us to refer to you in any formal documentation, such as a report?First / Home LanguageAre there any cultural or family values, traditions, or beliefs that are important to your family, that you would like us to be aware of as we work together?GP DetailsGP's name (if known) and Name of SurgeryStreet NameTown or CityPost CodePreviousNextEnsuring Safety of the Young Person, Family, and our Therapy Team If you respond “yes” to any of the five questions below, we will arrange a further call to discuss details. If you would prefer to discuss in a call without answering these questions, please select the option below.Is the Young Person a 'Looked After Young Person'/'Young Person Looked After'? Yes No Prefer to discuss in a callYou have indicated that the Young Person is a 'Looked After Young Person'. Please provide relevant details if you are happy to do so.Does the Young Person have a Child Protection Plan or have they been subject to Child Protection in the past? Yes No Prefer to discuss in a callYou have indicated that the Young Person is or has been subject to Child Protection. Please provide relevant details if you are happy to do so.Has the Young Person made any allegations of being harmed in any way, regardless of the outcome of any investigation? Yes No Prefer to discuss in a callYou have indicated that the Young Person has previously made allegations of being harmed. Please provide relevant details if you are happy to do so.Has the Young Person ever displayed any harmful behaviours to other young people or adults? Yes No Prefer to discuss in a callYou have indicated that the Young Person has previously displayed harmful behaviour. Please provide relevant details if you are happy to do so.Does your Young Person have any medical conditions that may impact on their engagement in therapy e.g. epilepsy, heart conditions, spinal conditions? Please note, this list is not exhaustive. It is important to raise anything at all that you think could be a cause for concern/could risk your Young Person's safety. Yes No Prefer to discuss in a callYou have indicated that the Young Person may have a medical condition that may impact on their engagement in therapy. Please provide relevant details if you are happy to do so.PreviousNextPregnancy and Birth HistoryWhat was the birthing parent's health during the Young Person's pregnancy?What was the length of gestation and the Young Person's weight at birth?What was the length of the Young Person's labouring?What was the Young Person's health at birth and were there any interventions carried out during or immediately after the birth?PreviousNextMedical InformationDoes the Young Person have any formally diagnosed conditions?Does the Young Person have any suspected but not formally diagnosed conditions?Does the Young Person take any prescribed medications?Does the Young Person take any non-prescribed or over-the-counter medications?Has the Young Person ever been admitted to hospital?When was the Young Person's last hearing test, and what was the result of this test?When was the Young Person's last sight/vision test, and what was the result of this test?PreviousNextFamily HistoryIs there any family history of speech, language, and communication needs?Are there any neurodivergent people within the family (e.g. Autistic, ADHD, dyspraxia etc) whether diagnosed or self-identified?Are there any learning difficulties within the family (e.g. dyslexia)?PreviousNextPaediatricianHas the Young Person seen a paediatrician, either in the past or currently? Yes NoPlease provide the paediatrician(s)'s names and their contact details.When did the paediatrician(s) support happen?Is the Young Person on a waiting list to be seen by a paediatrician? Yes NoOccupational TherapyHas the Young Person seen an occupational therapist, either in the past or currently? Yes NoPlease provide the occupational therapist(s)'s names and their contact details.When did the occupational therapy support happen?Is the Young Person on a waiting list to be seen by an occupational therapist? Yes NoSpeech and Language TherapyHas the Young Person seen a speech and language therapist, either in the past or currently? Yes NoPlease provide the speech and language therapist(s)'s names and their contact details.When did the speech and language therapy support happen?Is the Young Person on a waiting list to be seen by a speech and language therapist? Yes NoPhysiotherapyHas the Young Person seen a physiotherapist, either in the past or currently? Yes NoPlease provide the physiotherapist(s)'s names and their contact details.When did the physiotherapy support happen?Is the Young Person on a waiting list to be seen by a physiotherapist? Yes NoSocial WorkerHas the Young Person or the family been supported by social workers, either in the past or currently? Yes NoPlease provide the social worker(s)'s names and their contact details.When did the social worker support happen?Is the Young Person on a waiting list to be seen by a social worker? Yes NoChild and Adolescent Mental Health Services ('CAMHS')Has the Young Person or the family been supported by CAMHS, either in the past or currently? Yes NoPlease provide the CAMHS team member(s)'s names and their contact details.When did CAMHS support happen?Is the Young Person on a waiting list to be seen by CAMHS? Yes NoCommunity NurseHas the Young Person or the family been supported by community nurses, either in the past or currently? Yes NoPlease provide the community nurse(s)'s names and their contact details.When did the community nursing support happen?Is the Young Person on a waiting list to be seen by a community nurse? Yes NoIndependent Emotional or Mental Health supportHas the Young Person or the family been supported by an independent emotional or mental health support worker, either in the past or currently? Yes NoPlease provide the professional(s)'s names and their contact details.When did the support happen?Is the Young Person on a waiting list to be seen by an independent emotional or mental health support worker? Yes NoAny other professional involvementHas the Young Person or the family been supported by any other professionals, either in the past or currently? Yes NoPlease provide the other professional(s)'s names and their contact details.When did the support happen?Is the Young Person on a waiting list to be seen by any other professional(s)? Yes NoProfessional Reports It is exceptionally helpful for our clinical team to be able to review reports that you have received from other professionals in respect of your young person’s needs.Please use the below to upload any professional reports you have received dated within the past 12 months.Choose File(s) Please use the below to upload any other professional reports you feel may have relevance to your Young Person's case.Choose File(s) PreviousNextDevelopmental MilestonesWhen did the Young Person roll, crawl, sit, stand, and walk?When did the Young Person first babble, say their first word(s), and start linking words together?Did the Young Person use a dummy and/or suck their thumb? If so, when did they stop?Does the Young Person have a preferred hand for tasks (i.e. are they left or right handed)?FeedingHow does the Young Person feed?What was the Young Person's early feeding history?PreviousNextFamilyWhat adults does the Young Person live with, how old are they, and what is their relationship to the Young Person?Does the Young Person spend any time at other addresses? Yes NoPlease provide each additional address plus provide the names, ages, and relationships of the adults and young people living at each address.How much time does the Young Person spend at each address listed above?Who else is important to the Young Person? Please provide names and relationships for each.Home Environment Please note that this section must be completed for Occupational Therapy or Joint Therapy services. This section is optional for those receiving purely Speech and Language Therapy services (please put 'SLT only' into each field).What type of home does the Young Person live in?How many bedrooms does the Young Person's home have?Does the Young Person have their own room, or do they share?Does the Young Person's home have a garden?Is there access to any garden-based play equipment?What type of environment is the home's surrounding area?PreviousNextEducational HistoryWhat academic year is your Young Person in currently?Please list the names and dates of all past and current educational placements, along with the reasons for changing placements.Does the Young Person have a One Page Profile, Statement of Special Educational Needs (SEN), Individual Development Plan (IDP), or Education Health and Care Needs Plan (EHCP)?Please use the below to upload any One Page Profile, Statement of SEN, IDP, or EHCP that the Young Person may have.Choose File(s) PreviousNextStrengths and InterestsWhat does your Young Person love to do?What are your Young Person's areas of interest?What toys does your Young Person enjoy using or playing/engaging with?What is your Young Person great at doing?PreviousNext"A Day in the Life" Caregiver Questionnaire Please provide a general description of your Young Person’s daily life by responding to the headings below. Please describe what your Young Person can do for themselves and what you need to support them with, as well as how you support them (if applicable). You can also send us videos/pictures of your Young Person (with their permission, if possible) in their everyday life if you feel this will be useful to the assessment process. This could be examples of activities you feel it is important we see, or instances of them engaging in something fun/enjoyable. If we are going to be seeing your Young Person in an educational setting, it’s really helpful to have at least one photo so we know what they look like before the visit. You will be given the opportunity to attach videos and pictures at the end of this page. Please note that this section must be completed for Occupational Therapy or Joint Therapy services. This section is optional for those receiving purely Speech and Language Therapy services (please put 'SLT only' into each field).Waking UpMorning Personal Care RoutineBreakfastOff to Childcare or School (if they attend a setting)Lunch (when at home)Back from Childcare or School (if they attend a setting)Evening MealEvening and Weekend ActivitiesEvening Personal Care RoutineGoing to BedNight-time and SleepPlease provide any pictures or videos of your Young Person you feel we should see.Choose File PreviousNext"Hopes and Dreams" Caregiver Questionnaire Completion of this form ensures we are focussing on the right areas for you and your Young Person.What are your key concerns and areas of focus/query to be addressed by working with Helping Kids Shine?What are your key hopes of things to be achieved by working with Helping Kids Shine?If known, what are the Young Person's key concerns and areas of focus/query to be addressed by working with Helping Kids Shine?If known, what are the Young Person's key hopes of things to be achieved by working with Helping Kids Shine?Thank You! Thank you for your time, energy, and effort in completing this form - it is truly appreciated and will help us to understand your Young Person in much greater detail. This information will now feed into our second-stage triage process and we will be in touch with the next steps as soon as possible. Previous Submit Form
