First Your email address *
Informant's name * Informant's email address *
Reasons for Assessment *
Was it your idea or someone else's to seek this assessment?
Please tell us about your family *
eg do you have parents, siblings, spouse/partner, children, grandparents etc.?
Biological father's occupation * Biological mother's occupation * Number of full/ half siblings and your place * Any blood relatives showing similar symptoms? * How do you get along with your family? Who is closest to you? *
If you don't get along with any family members, why do you think this is?
How often do you have contact with your family and by what means? *
eg. text, face to face contact, talk on phone etc.
EARLY LIFE What was your mother's pregnancy like with you? Any difficulties or issues? Was your birth at, before or after expected date? *
You may not know the answer to these questions, please just provide the information you or informant have
Were you born by full term normal delivery and well after birth? * Were you an active baby and young child? Any other early characteristics? * Any delay in starting sitting up / walking / talking (early milestones) ? * What were you like as a baby? *
eg settled baby, cried a lot, didn't sleep, often sick etc.
Have you been / are you a clumsy person? What age did you first babble (in months)? * What age did you first talk (in years)? * What age did you first walk (in months)? * What age did you no longer need nappies (in years)? * What age did you first tie your shoelaces (in years)? *
Put zero if still not able to do it
What age did you first fasten and undo buttons (in years)? *
Put zero if still unable to do this
What age were you first able to use zips (in years)? *
Put zero if still unable to do this
What age did you first ride a bicycle (in years)? *
Put zero if still unable to do it
What age could you first throw and catch balls (in years)? *
Put zero if still unable to do this
Did you like cuddles as a child? *
If yes, was this with any specific people?
If you have siblings, did you like to play with them as a child or did you prefer to play alone? * If you did play with siblings, what types of games/play did you do? * What were your favourite toys as a child? * Did you ever collect toys/memorabilia? If so, what were they and do you still have them? * Did you go on holidays with your family? Did you enjoy them? * Did you attend family parties/gatherings? Did you enjoy them? * Did you have any significant illness, accident or specific needs that required intervention from professionals in your early childhood? * EDUCATION School Years *
School Years Please write below, what nursery, pre-school, infant, primary and secondary schools you went to and at what age:
Did you need to change schools at any time? If so, what were the reasons for this? * Did you ever get issued with a statement of educational need at school? If so, what was this for? * Did you receive any additional support in school to help you to engage in lessons or learn? If so, what was this support, and did it help? * Did you enjoy nursery? Why, or why not? *
Did you enjoy nursery? Why, or why not? Do you know what teacher’s feedback said about you? if so, what was it?
Did you enjoy pre-school? Why, or why not? *
Did you enjoy pre-school? Why, or why not? Do you know what teache’sr feedback was about you? if so, what was it?
Did you enjoy primary school (infants)? Why, or why not? *
Do you know what teache’sr feedback was about you? if so, what was it?
Difficulties in primary school * Struggled to listen/zoned out Fidgety Naughty/in trouble a lot Problems with authority/rules Difficulty with reading Difficulty with spelling Difficulty with handwriting Problems with maths/numbers Struggled with friendship Bullied Academic level at end of primary school (aged 11) ? * Describe your secondary school experience up to GCSE. How was it similar or different from primary school? *
Do you know what teachers' feedback was about you? if so, what was it?
Prior to GCSE did you? * • Struggled to revise • Homework not done/done last minute • Achieved potential How many GCSEs did you get with approximate grades? * Describe your sixth form school or college experience. What exams did you get with grades if remembered? Did you achieve your potential? * What subjects did you enjoy during school? * How well did you cope with the transitions between schools? * Did you make friends at school? If so, who were your friends at school? Did you see any friends out of school? *
If yes, what did you do? e.g., birthday parties, sleepovers, did you enjoy them?
Do you still see your old school friends? * Did you go to any clubs or do out of school activities? *
e.g., sports clubs, girl guides/boy scouts etc, did you enjoy these?
Did you do any further education after secondary school? If so, what did you do and what did you achieve? If you attended did you enjoy college/ university? Why, or why not? Did you achieve your potential? If so, what were they? * If you attended did you get on with other students when doing further education? Did you make any friends, if so, who were they? * EMPLOYMENT HISTORY Please describe your work history, with a focus on problems, patterns and reasons for leaving. You don’t have to list every job just a general picture including current occupation and future career aims/hopes *
If you have ever worked can you list the jobs you have done, and the years you worked at these jobs below:
For each job please list job role, employer and dates worked there, problems encountered and reasons for leaving
At work, have you had problems with any of the above? * • Lateness • Too much sick leave • Difficulties learning/remembering processes • Difficulties understanding conversations • Problems getting started and / or finishing projects • Boredom • Problems with rules/authority How well have you got along with your colleagues in work? *
e.g., did you form friendships, socialise out of work? Have you ever been bullied in the workplace?
Have you ever experienced any difficulties that resulted in you having to leave your job? If so, what were these? * COMMUNICATION Communication: Do people ever misinterpret what you say and mean? If so, in what way? * Do you ever misinterpret what people say to you or what they intend? If so, in what way? * Do you ever find it difficult to be in social situations with people you know, or you don’t know? If so why and what helps you cope in these situations? * Can you easily understand non-verbal communication? *
e.g. body language, gesture, facial expression, group dynamics etc If you struggle with any, which ones are more difficult for you?
Do you understand humour, banter, sarcasm, metaphors or euphemism? If you struggle with any, which ones do you find more difficult to understand? * Are you able to imagine how other people may be feeling? If not, in what way do you struggle with this? * Can you feel empathy? And are you able to show empathy? How do you express it? * Can you initiate conversations? Can you maintain conversations with people even if the topic does not interest you? If not, what do you struggle with? * Are you able to routinely look people in the eyes when you talk to them? Do you routinely use gestures and change the tone of your voice to enhance what you are saying to someone? If you struggle with any of these, which ones and what do you find difficult. * Do people describe you as an opinionated person? *
Do you have black and white thinking?
Do you think literally?
ROUTINES, RIGIDITY AND FOCAL/REPETITIVE INTERESTS/SENSITIVITIES Do you currently have any routines? If so, what are these? e.g., things that you like to do at a set time or in a set way? * Do you have difficulties coping with change? *
e.g., if your plans change unexpectantly. If so, can you give some examples and how it affects you?
How do you spend your time at home? Are you satisfied with how you spend your time? * Do you like having any order to your belongings? If so, can you provide examples? * If you have to do something new or go somewhere new, how do you prepare yourself? * What are your interests? How much time each week do you engage in these interests? * Do you do anything repetitively and if so what? *
e.g., buy same brands, eat same foods, repeated body movements, intense interests etc.
Do you have any sensitivity to light, sound, taste, smell, touch? If so which ones and in what way? * PRESENT SOCIAL CIRCUMSTANCES Do you live alone or with other people? If you live with other people, who are they? * Are you currently working or in education? If so, what are you doing? How many hours is this each week? * In relationships and friendships, do you struggle with? * • Shyness • Boredom • Jealousy • Oversensitivity and / or overthinking • Feeling suffocated or overwhelmed by others Are you currently in a romantic relationship?Please describe your relationship history. No need to list everything, just the pattern, longest relationship, any issues and why they end. What do you hope for going forwards? * Do you have any friends? If so, who are they, how long have you known them and how often do you have contact with them? * Are you involved in any clubs, groups or other organised e.g. cultural or spiritual activities? If so, what are these and how many hours each week do you participate in them? * PSYCHIATRIC AND MEDICAL HISTORY Do you have any health conditions (physical or mental)? If so, what are these? * Are you currently receiving any treatment for a condition? If so, what? e.g. medication, counselling, talking therapy * Are you receiving input from any specialist agencies/health professionals? If so, who? * Have you struggled much with low mood? Ever taken antidepressants or other mental health medications? * What about anxiety? What makes you anxious? Are you a very anxious person? Ever had a panic attack? * Briefly summarise any therapy/ counselling you have had and when. Did it help at all and if so, how? * Have you ever been in trouble with the law? * Any sleeping issues, past or present. Do you use any specific strategies to help with sleep? * Please describe any eating disorders or problems past or present? * Do you have any issues with alcohol or drugs past or present. How much alcohol/ drugs do you use currently, and how often? * Do you drive currently? * As a child were you slower/ worse than others with learning to tie shoelaces, ride a bike etc.? * Were you clumsy as a child? * As an adult, do you have problems with distinguishing left and right or finding your way around? * ACTIVITIES OF DAILY LIFE Are you able to cook? Independently or with support? * Are you able to shop for food? Independently or with support? * Are you able to shop for clothes? Independently or with support? * Are you able to do housework? Independently or with support? * Are you able to do your laundry? Independently or with support? * Are you able to make appointments? Independently or with support? * Are you able to attend appointments? Independently or with support? * Are you able to use public transport? Independently or with support? * Are you able to manage money? Independently or with support? * Are you able to use a phone? Independently or with support? * Are you able to drive? Independently or with support? * Are you able to ask for help? Independently or with support? * Is there anything else that would be helpful for us to know?