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This service is provided by Virgin Care Services Limited on behalf of itself and a number of related organisationsRegistered office: 6600 Daresbury Business Park, Warrington, Cheshire WA4 4GE. Registered in England and Wales Number 5466033 Form revision 6

Virgin Care JADES Referral Form

We require supporting information alongside this referral:

Please complete the essential screening tool and include the score below

Essential : M-CHAT Autism questionnaire for under 4 years old Essential : AQ10 questionnaire for 4 years old +

M-CHAT Questionnaire score (under 4 years)………………………….

AQ10 Questionnaire score: Child (4-11 years)………………

Adolescent (12-15 years)…………… Adult (16 years +)………………….

Desirable: ASQ-SE for pre-school children only (completed by a Health Visitor or Healthy family support worker)

ASQ-SE score (for pre-school children only)…………………………

Desirable: Any other reports from other professionals involved in child’s care

It is also helpful to have information from more than one person/ setting, eg: parents and Health Visitor.

Completed by:______________________________ Information collated from: ____________________

Commissioned by:

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1. Child / Young Person InformationSurname Forename/s Date of birth NHS number

(if known)Languages

spoken Translator Required

Yes / No

2. Family / Carer Information Parent/carer

nameRelationship to child / young person

Contact details

Home:

Mobile:

Email:

Address Parental responsibility

Yes / No

Parent/carer name

Relationship to child / young person

Contact details

Home:

Mobile:

Email:

Address (if different from above)

Parental responsibility

Yes / No

3. GP InformationGP name GP surgery / practice

4. Child / Young Person – Nursery / Education Setting

Consent to Contact School directly: Has consent from parent / carer been obtained for Virgin Care Ltd to Contact the child’s school directly, in order to obtain information related to this referral and invite them to attend diagnostic clinic? YES / NO

Commissioned by:

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5. Social Care InformationDoes the child / young person have a Child

Protection Plan?

YES / NO

Has the child ever been on a Child in Need or Child Protection Plan?

YES / NO

Is the child / young person a looked after

child?

YES / NO

Does the family have an

allocated social worker?

YES / NO

Name:

6. Child Medical HistoryDoes the child / young person have existing medical conditions and/or mental health difficulties? YES / NO (If yes, please state)

Do they take any medications? YES/NO (If yes, please state)

Were there any complications during pregnancy and birth?

Were there concerns about the child’s developmental milestones? (e.g. info in parent Red Book)

7. Child / Young Person – Family and Social HistoryPlease tell us about anyone in the family who has or is suspected to have learning difficulties, ADHD,

mental health difficulties, developmental problems, language problems or autism spectrum disorder.

Please tell us about significant or adverse life experiences, which could possibly be relevant to making

sense of the child/young person’s emotional wellbeing and behaviour.

Commissioned by:

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8. Reason for referral to JADES:Area of development Concerns (Y/N) Please give details

Spoken language – single words, short phrases, sentences; echolalia; learned language; odd words and phrases; idiosyncratic speech (please give examples)

Responding to others – do they respond to their name; do they respond when someone joins them in play. When a conversation is started how do they respond?

Interacting with others – do they seek others out, do they start conversations with others? Prefer interacting with adults rather than peers?

Commissioned by:

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Eye contact, pointing and other gestures e.g. can they maintain and modulate eye contact with others; vocalizations usually accompanied by subtle changes in gestures, gaze and facial expressions; point to express interest.

Play and imagination – please describe how the child/young person plays and what their preferred choices are. Is the play appropriate for their age? Do they have a range of interests?

Unusual or restricted interests – Are they fascinated by a particular topic/ item to an intense degree? If yes, please give an example. Are they interested in unusual items e.g. pegs; batteries; stones.

Commissioned by:

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Rigid and/or repetitive thinking including routines and rituals – e.g. do they have certain routines and rituals they need to complete; do they say things in the same way and/ or insist others do; do they insist on always following the same route to a destination.

Repetitive body movements – e.g. hand flapping; spinning items or themselves; complex mannerisms

Over or under reaction to sensory stimuli – Sensory defensiveness e.g.: aversion to loud noises – hoover/ hand dryer; aversion to clothes’ tags. Sensory seeking e.g. looking at light through fingers; playing with water; running sand in fingers.

Commissioned by:

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9. Other current concerns:

Area of development Concerns (Y/N) Please give detailsEmotional wellbeing/behaviour – Do they know how to emotionally regulate themselves? How do they express their feelings?

Attention and concentration – How long can they attend to an activity? Can their attention be shifted to another activity?

Motor skills (fine and gross) – Are there any concerns with e.g: walking, running, climbing, holding a pencil/ knife and fork.

Commissioned by:

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Learning and memory e.g. are they attaining at school; can they retain information.

Eating e.g. aversion to certain foods; restrictive food choices according to colour, texture, brand.

Toileting e.g. toilet trained; smearing.

Sleeping e.g. difficulties with sleep onset; waking during the night; early rising.

Commissioned by:

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Other – any additional information pertinent to the referral.

10. Additional Information:Please tick below any other services who have been involved in the child / young person’s support:

Audiology

Optician

Health Visitor

EWMHS (Emotional Wellbeing and Mental

Health Service)

Educational psychologist

Speech and Language Therapy

Occupational Therapy

Physiotherapy

Paediatrician

School nurse

Children’s Learning Disability

Service (CLDS)

Social Services

Preschool specialist teacher

team

Specialist teacher team (e.g. behavior

support)

Other

Please attach reports and evidence to support referral from the agencies circled above with this referral form.

11. Consent:Consent for Referral:Has consent from parent / carer been obtained for referral? YES / NO

Commissioned by:

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Consent to obtain information from other agencies:Has consent from parent / carer been obtained for referral? YES / NOConsent to share information:Has consent from parent / carer been obtained for sharing of information with other professionals? YES / NOConsent to Observe Patient:Has consent from parent / carer been obtained for Virgin Care Ltdstaff to observe the patient in an educational setting? YES / NO

Parent Name Parent signature Date

12. Referrer Information:Name of referrer Profession Contact details

Mobile:

Work:

Email:

Address

Signature Date of referral

Thank you for your cooperation, please return to: Virgin Care Single Point of Access, Virgin Care Administration Centre, Kao Park 2,

Hockham way, Harlow. CM17 9SR.

Or by Email to:

[email protected]

Commissioned by:

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mailto:[email protected]

name · web viewor repetitive thinking including routines and rituals – e.g. do they have certain...

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