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Pre ADI Informant Form

This document requests background information on a child's developmental history, including details on biological parents, siblings, family medical history, education and schooling, diagnoses, daily living skills, speech and language development, and sensory processing. Sections address names, dates of birth, developmental issues, schools attended, support received, diagnoses and ages at diagnosis, activities of daily living, motor skills, sensory processing, speech milestones, communication abilities, and play engagement. The goal is to gather a comprehensive developmental profile of the child.

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aspire center
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208 views6 pages

Pre ADI Informant Form

This document requests background information on a child's developmental history, including details on biological parents, siblings, family medical history, education and schooling, diagnoses, daily living skills, speech and language development, and sensory processing. Sections address names, dates of birth, developmental issues, schools attended, support received, diagnoses and ages at diagnosis, activities of daily living, motor skills, sensory processing, speech milestones, communication abilities, and play engagement. The goal is to gather a comprehensive developmental profile of the child.

Uploaded by

aspire center
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Background Information

Details of any developmental difficulties


Name
(e.g. Autism, ADHD, speech delay, dyslexia) or mental health problems

Biological Mother

Biological Father
Name(s) of caregiving parents (if different from above):
Details of developmental or mental health problems within the extended family:

Relationship Details of any developmental difficulties


Names of Siblings Date of Birth Age Sex (e.g. full sibling, adoptive (e.g. Autism, ADHD, speech delay, dyslexia) or mental health
sibling, half sibling) problems

1.

2.

3.

4.

5.
Please continue on additional paper if required.
Education and Schooling

Please provide as much information as possible about toddler groups, nurseries, schools and further education:
Type of school Age when attended
Name of nursery / school Additional support? Grades
(e.g. mainstream, independent, From To
/ college / university If yes, please provide details achieved
special school) (_Years_Months) (_Years_Months)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
Has your son/daughter ever received an Individual Education Plan (IEP), Statement of Special Educational
YES / NO (please delete as appropriate)
Needs (SEN), or Education Health Care Plan (EHCP)?
Age when statemented Details of statement (e.g. hours per week, focus of support):
(____Years____Months)

Existing Diagnoses

Age when diagnosed Type of professional who made diagnosis


Diagnosis Any additional information
(____Years____Months) (e.g. psychologist, psychiatrist, pediatrician)
Daily Living, Sensory and Motor Functioning

Has your son/daughter ever had difficulties managing basic activities of daily living? Such as dressing,
feeding and self-care?

Does/did your son/daughter engage in a variety of activities in their free time?


On own (structured and unstructured) With others (structured and unstructured)

Has your son/daughter ever had difficulties using their body? E.g. fine motor skills (doing up buttons, writing
or playing video games), gross motor skills (walking, running, kicking or throwing a ball)

Has your son/daughter ever experienced sensory processing difficulties? (e.g. touch, hearing, taste, smell,
sight, or internal sense of body awareness and movement)
Speech and Language

Has your son/daughter ever received Speech and Language Therapy? YES / NO (please delete as appropriate)
Age when started Frequency of Age when finished Focus of sessions
Who suggested referral? Age when referred One-to-one or
sessions sessions (e.g. sessions (e.g. delayed speech,
(e.g. parent, health visitor, GP (_Years_Months) group sessions?
(_Years_Months) weekly, monthly) (_Years_Months) pronunciation)

Milestones
Age when first used single words Age when first used simple phrases including
(other than ‘mama’ / ‘dada) a verb (e.g. “go park see ducks”)
(___Years___Months) (___Years___Months)

Examples: Examples:
How does the son/daughter communicate his/ her needs now? What for? Please provide examples.

Have you ever had difficulties with communicating with your son/daughter, either understanding them or
them understanding you?

As a child, could your son/daughter understand words across different contexts and show their
understanding by getting/showing?

Were you able to engage in play/activities with your son/daughter during childhood? How long did this last?
Please provide examples.

Signed: ___________________________________ Date: ____________________________________

Print Name: ___________________________________________________________________________

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