Red Questions are the main questions Blue Questions are the sub Questions
Q~ About the Child
A~ Fill in this section ! child ref No you will find on the letter you received with this form.
Tick all boxes ! except blind/partially sighted…..has hearing problems…….has physical disabilities unless these apply.
Q~ Walking Outdoors
A~ Tick Yes ! In the box write something like this ………..My child tires very quickly & is clumsy therefore he trips & falls often. We use a Major Stroller to contain & restrain him/her as they are prone to running away & also find crowds distressing which cause him/her to be Hyper & panic. My child is also prone to attacking anyone who gets too close. The buggy helps in restraining & controlling him/her it also helps him/her feel safer & secure.
Q~ How many days a week ?
A~ Every day
Q~ How far can the child walk
A~ 50 Metre’s
Q~How long does it take them to walk this far ?
A~15-20 minutes
Q~If the child needs someone with them when they are outdoors ?
A~Tick Yes ! In the box write something like this:- My son/daughter needs someone with them at all times outdoors as they are Severely Mentally Impaired , he/she has behavioural problems & severe learning difficulties , he/she has no sense of fear & will therefore bolt & run into the road , putting himself/herself in danger & endangering other people , he/she needs constant encourage to stay calm , needs almost constant soothing . He/she would wander off & get lost & would then be unable to ask for help , he/she would walk away with any person who approached them . He/she tends to violence when upset & would attack anyone coming too close. He/she is unable to ask/find a toilet & use it unaided & needs prompting & encouraging to use it , he/she would be unable to to procure food/drink & unable to feed/drink them selves & he/she needs promting & encouraging to feed/drink . He / she is incontinent & still in nappies .(if this applies).
Q~Someone to keep an eye on the child
A~Tick yes !Write something like this for during the day;- My son/daughter needs someone with them at all times as they are Severely Mentally Impaired , he/she has behavioural problems & severe learning difficulties , he/she has no sense of fear , & does not recognise danger signs , putting himself/herself in danger & endangering other people , he/she needs constant encourage to stay calm , needs almost constant soothing . He/she tends to violence when upset & often attack . He/she is unable to ask for a toilet & use it unaided & needs prompting & encouraging to use it , he/she needs promting & encouraging to feed/drink . He/she is incontinent & still in nappies .(if this applies). He/she is unable to take medication unaided .
Q~How Many Days A Week ?
A~7 days a week
Q~How much of the day do they need some with them ?
A~Work out the time the child normally gets up in the mornings & the time it normally goes to bed in the evenings ! the answer to the Q is the hours in between .
Q~ Roughly how long do they need someone with them each time during the day ?
A~15minutes-2hours
Q~Why the child needs someone with them during the night ?
A~Write something like this:- My son/daughter is incontinent & wets the bed every night , he/she soils during the night & requires changing , including the bedding ! he/she will require washing if she/he soils . He/she becomes very upset at needing changing & having wet/soiled & it is difficult to change him/her taking a great deal of coaxing & calming ! It is then difficult to re-dress him/her again require lots of coaxing & calming . It then takes a long time to settle him/her back down for the rest of the night , may even require further sleeping medication .
Q~How many nights a week ?
A~ 7 days a week
Q~How much of the night does someone have to be awake ?
A~Minimum of 2hrs
Q~How long do they need someone awake with them each time ?
A~Minimum of 2 hours
Q~About your childs developement ?
A~Tick Yes ! write something like this :- He/she has difficulties cutting up food , speech is echolic , or non verbal (which ever applies) walking is tiring for him/her , He/she has an aversion to hot/cold food , He/she cannot eat normal food , He/she has an aversion to noise/hypersensitive hearing ! certain sounds alarm Him/her . He/she has temper tantrums.
Q~How many times a day does the child need help ?
A~15-30 times a day
Q~How long does it take each time ?
A~20minutes -2hrs
Q~Does the child have a delay in their developement of learning skills ?
A~Tick Yes ! write something like this :- My son/daughter lives in a world of his/her own , he/she is often not even aware of people around him/her . He/she cannot follow simple instructions , he/she has to be coaxed/encouraged/assisted to do even simple things , at times he/she will simple refuse to follow instructions & has to be coaxed/encouraged/assisted to follow the instructions. Certain sounds especially loud sounds scare & upset him/her & he/she will require calming & soothing .
Q~How many times a day does the child need help ?
A~15-30 times a day
Q~how long does it take each time ?
A~20 minutes to 2 hours
Q~ Does the child have a delay in their development of social skills ?
A~Tick Yes Write something like this . My son/daughter has a communication problem , there is little or no eye contact , he/she lives in a world of their own , only plays on their terms , plays on their own in a crowd , does not approach other children/adults to play .
Q~ Roughly how many times a day does the child need help ?
A~ 20-30 times a day
Q~ Roughly how long does it take each time ?
A~1-20 minutes
Q~Does someone need to help the child develop through play ?
A~Yes write something like this . Play is repetitive , we have to monitor the toys he/she plays with & rotate them , he/she does not play appropiately , has little or no imagination , left unattended he/she would simply line up toys . Needs encouragement to take turns ,
Q~Roughly how many times a day does the child need help ?
A~5-10 times a day
Q~Roughly how long does it take each time ?
A~5-30minutes
Q~Waking , getting up & going to bed ?
A~Tick Yes !
Q~Does some have to wake the child or encourage them to get up or go to bed ?
A~Tick Yes ! write something like this :- My son/daughter sleeps very badly & it is a struggle every night to get them into bed & to keep them there. My son/daughter will refuse to go to bed & falls asleep eventually where ever they happen to be ! & then he/she will need to be carried to bed . My son/daughter will eventually go to bed but will not remain there & has to be encouraged & put back into bed numerous times until eventually he/she falls asleep .
Q~How many days a week does the child need this help ?
A~7 days a week
Q~How many times a day does the child need this help ?
A~once a day (twice if a younger child who needs a mid-day nap)
Q~How long does it take the child to get out or into bed ?
A~10mins-3hours
Q~Washing & bathing ?
A~Tick Yes !
Q~ does someone have to tell or encourage the child to wash or bath or shower ?
A~Tick Yes ! write something like this :- My son/daughter will not bath or wash without encouragement & assistance , sometimes even not then ! At times I have to bodily lift him/her into the bath/shower , he/she needs to be encouraged to actually wash , or I have to wash him/her myself . My son/daughter hates having his/her hair washed & I have to do it myself . My son/daughter has very sensitive gums & refuses to clean his/her teeth & needs encouragement & assistance to perform this task. My son/daughter has no sense of fear so has to be watched whilst in the bath/shower as he/she is likely to empty bottles etc & to play with the taps , possibly causing himself/herself an injury .
Q~How many times a day does the child need this help ?
A~twice a day
Q~How many times a day does the child need help with washing or bath/shower ?
A~ twice
Q~How long does it take to have a bath or shower ?
A~45minutes to 90minutes
Q~Getting dressed or undressed ?
A~Tick Yes !
Q~Does someone have to encourage the child to get dressed/undressed ?
A~Tick Yes ! write something like this :- My son/daughter is unable to dress/undress him/herself , he/she has no idea what clothes are appropriate , & his cor-ordination makes it difficult for him/her to cope with things like briefs & socks . He/she hates getting dressed/undressed & it is a struggle to do it.
Q~how many times a day does the child need this help?
A~7 days a week
Q~How many times a day does the child need this help ?
A~3-6 times a day
Q~How long does it take the child to get dressed/undressed each time ?
A~10minutes - 45minutes
Q~Help with toilet needs ?
A~Tick Yes !
Q~Does someone have to encourage the child to see to their toilet needs ?
A~Tick Yes !
Q~during the day ?
A~write something like this :- My son/daughter needs constant encouragement to see to his/her toilet needs & also needs assistance/encouragement with clothing . My son/daughter wears Nappies/pull ups .
Q~During the night ?
A~write something like this :- My son/daughter wears nappies/pull ups at night but needs changing during the night due to wetting/soiling . My son/daughter has to be lifted during the night & encouraged to use the toilet .
Q~How many days a week ?
A~7 days a week
Q~How many times does the child need this help ?
A~during the day ! 6-8 times……..during the night ! 1-3 times
Q~How long does it take each time ?
A~10-20 minutes
Q~Communicating with other people
A~ YES write something like this . My son/daughter cannot understand or follow simple instructions . These may need to be explained numerous times what is required of him/she , we use PEC cards to show him/her what he/she needs to be doing . We use Makaton to gain his/her attention . At times we have to touch him/her or turn his/her head toward us to gain his/her attention .
Q~How many times a day do they need someone to help them understand other people ?
A~ 20-30times
Q~Roughly how long does it take each time ?
A~5-15mins each time
Q~Does the child need help being understood by other people ?
A~Yes write something like this . My son/daughter has a speech & language disorder , he/she has finds communicating very difficult , he/she has no speech & uses PECS or Makaton , noises or gestures . Speech is often Echolic & Inappropriate. Which ever applies !!!!
Q~How many times a day do they need help to make themselves understood by other people ?
A~10-20 times
Q~Roughly how long does it take each time ?
A~5-15 minutes each time
Q~Is the child unwilling to communicate with other people ?
A~Yes write something like this . My son/daughter has a communication disorder & lives in a world of their own , he/she is often distressed , he/she is often withdrawn or very difficult to handle or hyper .
Q~Tellus about the encouragement the child needs to help them communicate with other people
A~write something like this . He/she needs to be encouraged to look at people when speaking or being spoken to . He/she will often not listen at all & the more you try to communicate with him/her the more distressed he/she becomes . He/she uses Makaton or/and PECS and/or noises or gestures to communicate . He/she can speak but speech is echolic & inappropriate .
Q~How many times a day do they need help to communicate with other people ?
A~5-20 times a day
Q~ Roughly how long does it takes each time ?
A~5-15 minutes each time
Q~Eating and drinking
Q~Does the child have difficulties eating or drinking ?
A~Yes
Q~Does the child need to be encouraged to eat or drink ?
A~Yes
Q~Tell us about the help or encouragement the child needs during the day
A~write something like this . Cannot cope with cutlery , uses fingers , cannot cut up food , will not eat food hot/cold . Will only eat certain foods . Will only eat soft food like baby food . Is a very messy eater often has to be fed .Will not remain at the table constantly runs off . Food cannot touch each other on the plate .Uses special children’s cutlery/ High chair / restraints . Will only eat from certain plate , drink for certain cup .whichever applies !
Q~Tell us about the help or encouragement the child needs during the night
A~If he/she wakes during the night , he/she may need feeding he/she will need to be encouraged to eat or drink
Q~How many days/nights does the child need this help ?
A~7 days/nights a week
Q~How many times a day/night does the child need this help ?
A~ Day = 4-7 times a day Night = 1-3 times a night
Q~How long does it take each time ?
A~5-20 minutes each time
Q~Help with medication ?
A~Tick Yes ! For during the day write something like this :- My son/daughter will not co-operate with taking any medication at all , it is always a terrible struggle , sometimes we do not even succeed in getting hi/her to take it . He/she cannot manage his/her inhaler without coaxing & assistance . He /she will not permit creams / plasters to be applied either .
A~For at night write something like this :- My son/daughter needs to take further sleep inducing medication , which is again a terrible struggle .
Q~How many times a week/night do they need this help ?
A~7 days a week —-7 nights a week
Q~How many times a day/night do they need this help ?
A~4 times a day ——-once a night
Q~How long does it take each time ?
A~10-45 mins
Q~Help with Therapy ?
A~Tick Yes ! for during the day write something like this :- My son/daughter needs help with therapy , he/she needs coaxing / encouraging /soothing & directing during speech Therapy & play therapy .
A~For the night write NONE
Q~How many days a week/nights a week does the child need this help ?
A~2/3 days a week for during the day——–None at night
Q~How many times a day/night does the child need this help?
A~1or 2 a day——-None at night
Q~How long does it take each time?
A~30-60 minutes during the day——–None at night.
Q~Help with medical equipment ?
A~tick No ! unless this applies
Q~Blackouts , fits , seizures or something like this !
A~Tick No ! unless it applies ! if it does write exactly what happens before , after & during a fit .
Q~The child’s Mental Health
A~Tick Yes! Write something like this :- My son/daughter gets anxious & suffers panic attacks & becomes Hyper in crowded places & cannot cope at all . He/she gets very frustrated when unable to complete a task . During these outburst he/she becomes violent towards others & is prone to attacking . he/she also becomes verbally aggressive & will throw objects or try to destroy them . The smallest change to his/her routine can tigger this behaviour , even being told “no” .
Q~How often does this happen & how long does the child need help ?
A~write something like this :- This outburst , panic attacks etc. happen on a daily basis , & numerous times in one day often with in minutes of each other . 10-20 such outbursts a day , 10-45 mins to calm him/her down each time .
Q~ Movement & co-ordination
A~Tick No ! unless it applies
Q~Moving about in doors
A~Tick Yes !
Q~Does someone have to tell or encourage the child to move about in doors ?
A~Tick YES! write something like this :- My son/daughter often refuses to leave the house & if coaxing fails he/she has to bodily lifted into his/her stroller , we use stair gates around the house to contain him/her to rooms where it is safe for him/her to be . He/she frequently requires bodily lifting into the bath/shower .
Q~When the child is in bed at night
A~Tick YES! write something like this :- My son/daughter has nightmares & disturbed sleep he/she often needs reassuring/comforting during the night . he/she is a very restless sleeper & often throws the covers off & cannot retrieve them , he/she frequently wets the bed which then requires resheeting , he/she will not remain in bed once awake & has to be given sleep inducing medication to settle them back to sleep , the medication takes an hour to work , during that time I will have to put him/her back to bed several times .
Q~How many nights does the child need help ?
A~7 nights a week
Q~How many times a night does the child need help ?
A~1-3 times a night
Q~How long each time ?
A~10-120 mins
Q~Help the child needs when they go out during the day or in the evening
Daytime/Evening
1 Swimming :-Taking him/her there , undressing , supervising , drying , redressing , toiletting , refreshments , communicating , taking him/her home again . 2 days a week——-once a day 2 hours
2 Dr’s/Hospital; Appointments :- Taking him/her there , refreshments , toileting , supervising , coaxing , soothing , communicating , taking him/her home. once /twice a week 1-2 hours
3 Hairdressers:-Taking him/her there , refreshments , toiletting , supervising , coaxing , soothing , communicating , taking him/her home. once a month 60-90 minutes .
At Home
1 Have family/friends to visit :-Refreshments , toileting , supervising , coaxing , soothing , communicating. 2 days a week——-2 hours each day
2 Play outside:-Refreshments , toileting , supervising , coaxing , soothing , communicating. 7 days a week———1 hour each time .
3 Painting/colouring/working on the computor:-Refreshments , toiletting , supervising , coaxing , soothing , communicating , instructing . 5 days a week———1hour each time.
Q Anything else about the way the child is affected by their illnesses or disabilities
Here you can write about his/her schooling , problems at school , about their Educational statement . Special Nursery school , special play groups , ARC units , etc anything else you feel the need to say !
Q~ About the child’s condition
A~write the approx date you first noticed your child had probelms .
Q~Do you think the child will still have the problems in 6 months ?
A~Tick YES ! then write beside it ! FOR LIFE !
DECLARATION
Sign & date
Ask someone to fill this section in ! Your Health Visitor is usually a good person to do this.
October 28th, 2008 at 7:38 am
I am currently carrying out a study on ‘fathers perceptions of ASD’ and wondered if you would be willing to pass my details on to any fathers of children with an ASD that may wish to contribute to my research. This only involves completing a questionnaire and confidentiality will be guaranteed.
Many thanks
Jenny