Autism pathway pre- assessment questionnaire

1 ADHD and Autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5 PNRelationship statusPlease tick:SingleMarriedDivorcedSeparatedWidow edLiving with partnerIn relationship but not living togetherPrefer not to answerAutism pathway pre- assessment questionnairePlease complete this questionnaire and return it to us before your initial appointment in the stamped addressed envelope provided. Providing this information will help us to know more about you and reduce the amount of questions we need to ask during your appointment. Please note all information is strictly for completing the questionnairePlease tick any YES/NO questions and answer all questions, providing additional details where necessary.

2 If you are unable to complete the questionnaire , or would like a member of the team to support you, please contact us on 01924 316490 and we will be happy to help. Contact informationNameAddressDaytime telephone numberMobile telephone numberEmail addressPlease provide the name of your next of kinContact telephone number/address of your next of kinYour personal informationDate of birthPlace of birthCurrent relationship statusADHD and Autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5 PNAre you in agreement for your carer to be contacted and involved in your care from our service?Yes No Please give the details of everyone living with you/at your addressCurrent accommodation statusAccommodation statusPlease tick:Living aloneLiving with partnerLiving with parentsSheltered/temporary accommodationNo fixed addressOther (please specify):Do you have a carer?

3 Yes No If yes, name and address of your carerNameGenderDate of birthRelationship to you (eg. wife, daughter, adopt-ed son etc.)Details of any mental health /physical health /other diagnosesADHD and Autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5 PNDisability Living Allowance/PIPE mployment Support AllowanceHousing BenefitOther (please give details)Yes No Yes No Yes No Yes No Yes No Yes No Have you ever been investigated by the Police or charged with a criminal offence? ( cautions/convictions/court appearances/imprisonment)Are you currently receiving any of the following benefits?

4 If yes, please give further details including charges and dates:What type of school did you attend? Have you ever received a Statement of Special Educational Needs (SEN) or had an Educational health Care Plan (EHCP) during your education? EducationSchool type Please tick:Mainstream state schoolMainstream private schoolSchool for children with behavioural and/or emotional difficultiesSpecialist school for children with autismSchool for children with severe learning disabilitiesSchool for children with moderate learning disabilitiesSchool for children with physical disabilities and/or sensory impairmentsLanguage unit within a schoolOther (please specify):ADHD and Autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5 PNPlease state your highest level of qualification to date:Qualification Please tick.

5 O level/CSE/GCSEAS LevelA LevelBTEC or equivalentNVQH igher National DiplomaFirst degree or equivalent professional qualificationHigher degree ( Masters, PhD)Other (please give details):EmploymentAre you currently in paid employment? Please give a brief list of your past employment to date and why you left: Yes No Dates (year)CompanyJob titleType of workWhy you leftADHD and Autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5 PNFamily structurePlease complete the following information about your mother:NameIs she: Living DeceasedAgeOccupationHas your mother ever been diagnosed with a mental health condition or other diagnosis?

6 Please complete the following information about your (birth) father:NameIs he: Living DeceasedAgeOccupationHas your father ever been diagnosed with a mental health condition or other diagnosis?If yes, please could you give us some details?If yes, please could you give us some details?Has your mother ever been diagnosed with any physical health conditions? Has your father ever been diagnosed with any physical health conditions? If yes, please could you give us some details?If yes, please could you give us some details?Yes No Yes No Yes No Yes No ADHD and Autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5 PNDo you have any children who do not live with you?

7 Do you have any brothers or sisters?If yes, please complete the following information for each of your children. If yes, please complete the following information for each of your siblings. Yes No Yes No NameGenderDate of birthLiving or deceasedDetails of any mental health /physical health /other diagnosesNameGenderDate of birthLiving or deceasedDetails of any mental health /physical health /other diagnosesADHD and Autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5 PNPlease could you give information about any other family details you think may be relevant? ( stepchildren, previous marriages, adoptions, foster care, other family members such as grandparents who may have a mental health condition):Please give details of any allergies and the current medication you have been prescribed for either mental health and/or physical health reasons.

8 Please include name, dosage and what it is prescribed and address of your GPDo you:Medical historyAllergies:Allergic to:What happens when exposedSmoke cigarettes/tobacco? If yes, how many cigarettes do you smoke a day?Smoke cannabis? If yes, how much cannabis do you smoke each day? ( number of joints, ounces of cannabis)Current medicationYes No Yes No 1-5 5-10 10-15 15-20 20+ADHD and Autism service, Manygates Clinic, Portobello Road, Wakefield, WF1 5 PNDo you have any diagnosed physical health conditions? Have you ever felt suicidal?

9 If yes, have you ever planned or attempted suicide? If yes, please give some details:Have you ever been diagnosed with the following? If yes, please give details: Autism spectrum disorder (including Asperger s) Tourette s syndrome Obsessive compulsive disorder (OCD) (General) Anxiety disorder Depression Dyspraxia Dyslexia Dyscalculia Learning disability or global developmental delay Any genetic disorder

10 Sleep disorder Visual problems Hearing problems Language delay or other language disorders Schizophrenia Bipolar disorder Personality disorder Substance misuse Any other mental health condition If yes, please give details.