Confidential Database for Children and Young People with a Disability/Special Needs Input Form

SECTION 1 - PERSONAL DETAILS OF CHILD/YOUNG PERSON
1.1 /

First name

/

Surname

Address / Sex / Male
Female
Postcode / Telephone (home)
Email / Telephone (mobile)
Date of birth / NHS number
1.2 / Name of nursery/school/college
1.3 / To which of these ethnic groups does your child belong? (Please tick one box)
a) White / Pakistani
British / Bangladeshi
Irish / Any other Asian background
(please specify)
Any other white background
(please specify)
d) Black or Black British
b) Mixed / Caribbean
White and Black Caribbean / African
White and Black African / Any other black background
(please specify)
White and Asian
Any other mixed background
(please specify) / e) Chinese
f) Other ethnic group (please specify)
c) Asian or Asian British
Indian / g) Prefer not to say
1.4 / Family GP name
Family GP practice
Family GP address
Family GP Tel No.
1.5 / Reason for your child being on the database: i.e. your child has a disability or special need. Please tick below which boxes apply to your child
Chronic or severe illness / Hearing impairment
Communication difficulty / Mental health
Development & learning difficulty / Physical disability
Emotional/behavioural difficulties / Visual impairment
Any other disability/special need or difficulty?
Please describe what these are.
1.5.1 / If your child has a visual impairment do they have a BD8 or Certificate of Visual Impairment (CVI)? / Yes
No
1.5.2 / If your child has a BD8 or CVI, are they certified as: / sight impaired (partially sighted)
severely sight impaired (blind)
1.6 / What in your own words is the diagnosis or difficulty of your child?
1.7 /

Language/communication requirements for information and advice of your child:

Does your child use sign language? / Yes
No /

If yes, which of the following do they use?

/ BSL
Makaton
Pecs
Signalong
Does your child use Braille? / Yes No
Please specify any other communication methods your child uses
1.8 / Personal attention required:
Where your child requires significantly more attention than other children of a similar age, please tick all that apply
Balancing/falling / Picking things up/holding pencil
Bed wetting / Playing
Combing hair/cleaning teeth / Reaching for things/combing hair
Controlling challenging behaviour / Relating to others
Dressing / Understanding others
Eating/drinking / Use of other mobility aids
Expressing needs/being understood / Using a wheelchair
Getting in/out bed / Using the toilet
Getting up/down stairs / Walking/moving about in a familiar environment
Night supervision / Walking/moving about in an un-familiar environment
Overcoming anxiety / Washing/bathing/showering
Personal safety / Other (please specify)
1.8.1 / Other attention required. Does your child require:
Continence aids? / Yes
No / If yes, when? / During the day
During the night
Special remedial exercise/equipment?
(Speech therapy, physiotherapy and occupational therapy) / Yes
No
Medical treatment?
(Provided by nurses visiting the home or during hospital visits) / Yes
No
Medication?
(Anything prescribed by a doctor) / Yes
No

Using a machine, e.g. suction, oxygen

/ Yes
No /

Nasogastric/tube feeding

/ Yes
No
1.9 / What services does your child currently receive from:
Health e.g. speech and language therapy, nursing, physiotherapy
Education e.g. special educational needs
Social care e.g. respite, homecare
Voluntary sector e.g. respite, play schemes
1.10 / Leisure activities & holiday play schemes:
Has your child attended a holiday play scheme in the last year? / Yes No
Has your child attended an out of school club in the last year? / Yes No
Has your child attended any leisure activities in the last year? / Yes No
1.11 / What other services do you think your child would benefit from?
Health
Education
Social care
Voluntary sector
Holiday play schemes / Sitting service
Leisure activities / Young carers support
Out of school care / Other. Please detail below
1.12 / Please tick if you require further information on the following services/benefits:
Allowances / Holiday play schemes
Consultation groups / Short breaks
Family Fund / Support groups
Leisure activities / Toy library
Out of school clubs / Young carers
SECTION 2 - PERSONAL DETAILS OF PARENT/MAIN CARER
2.1 /

First name

/

Surname

Title (Mr, Mrs, Ms, Miss, Dr) / Relationship to child
Address (if different to child) / Telephone (home)
Telephone (mobile)
Postcode / Email

What is the main language used at home?

Are you a lone parent?

/ Yes No

Do you have a disability/special need?

/ Yes No

Do you prefer information to be explained personally?

/ Yes No
2.2 / What is the child’s living situation? (for example: with parents, foster carer, residential school, residential home, shared care)
2.3 / Siblings:
What are the ages of any siblings?
Are the siblings involved with caring for their disabled brother or sister? / Yes
No
2.4 / Transport: What is the main form of transport you use with your child? / Private Car
Public Transport
Other. Please specify
2.5 /

Allowances: Does your Child receive any of the following:

Disability Living Allowance

/

Care

/ No
Low
Mid
High
/

Mobility

/ No
Low
High
2.6 / Allowances: Do you receive any of the following:

Income Support

/ Yes

No

/ Tick if you would like to receive further information
Working Tax Credit / Yes

No

/ Tick if you would like to receive further information
Carers Allowance / Yes

No

/ Tick if you would like to receive further information
SECTION 3 - SIGNATURE
The information you provide will be held by Merton and maybe used by the Council and other children’s centre partner organisations. This information will be used to help keep you informed about services for you and your family in your local area, it will also be used to help us monitor and improve those services in the future. If you have any further questions about the organisations who make up the Children’s Centre Teams or how your information will be used, please speak to a member of the team or visit:
www.merton.gov.uk/childrens_centre_database
I understand that completion of this form does not mean I am eligible for any statutory. disability services such as DLA or a Blue Badge
By signing this form I agree to the fact that my child is on the database being disclosed to relevant professionals who can demonstrate a need to know.
Further information will only be shared with your consent.
3.1 /

Signature of parent/main carer

/

Date

3.2 /

Name of worker who assisted with form

3.3 /

How did you hear about the database?

3.4 /

One of the benefits of your child being on the database is that we will send you regular updates on information on a wide range of services and activities. Please indicate below whether you are happy to receive:

Updates originating from the London Borough of Merton and/or Sutton and Merton PCT?

/ Yes No

Whilst we will not send out information on behalf of commercial companies, are you willing for us to send you information from voluntary organisations such as Contact a Family?

/ Yes No
3.5 /

I would prefer where ever possible to be sent information by:

/ Email
Post
Other format – please specify
SECTION 4 – COMMENTS
Please return to Family Information Advice and Guidance Team, London Borough of Merton,10th Floor Civic Centre, London Road, Morden, SM4 5DX

7