Disabled Children Index

First Name(s):

Surname:

Date of Birth (eg 15/02/1985):

	Gender:
	Female
	Male
	Non-binary

	First language:
	English
	Welsh
	Other

	If other please specify:

Ethnicity:

House name/number:

Street:

Town:

Postcode:

Email:

Telephone number:

Mobile number:

	Allowance reveived:
	N/A
	DLA
	PIP

School:

	Individual learning plan:
	Yes
	No

	Main reason for Registration:
	Developmental Delay
	Physical Disability/Chronic Illness
	Learning Disability
	Visually Impaired
	Hearing Impaired
	Speech/Language Difficulties
	Behavioural/Emotional Difficulties
	Communication/Socialisation Difficulties
	Autistic Spectrum Disorder
	Other

	If other please specify

	How does your child communicate? (Please tick all that apply):
	Speech
	PECS
	Makaton
	BSL
	Gestures
	Other

	If other please specify

Please give the name of your child's disability (if known):

Child's GP Surgery:

Child's GP:

Child's Hospital:

Child's consultant/consultants:

Parent/Carer:

Relationship to Child:

	Preferred language to receive information:
	English
	Welsh

	Is your child able to do the following:
		Yes		No		With help		Too young
	Walk/move about	Walk/move about Yes		Walk/move about No		Walk/move about With help		Walk/move about Too young
	Get up/down stairs	Get up/down stairs Yes		Get up/down stairs No		Get up/down stairs With help		Get up/down stairs Too young
	Eat/drink	Eat/drink Yes		Eat/drink No		Eat/drink With help		Eat/drink Too young
	Wash/bathe/shower	Wash/bathe/shower Yes		Wash/bathe/shower No		Wash/bathe/shower With help		Wash/bathe/shower Too young
	Use toilet	Use toilet Yes		Use toilet No		Use toilet With help		Use toilet Too young
	Dress	Dress Yes		Dress No		Dress With help		Dress Too young

	Other reasons for registration:
		Mild		Moderate		Severe		Under Assessment
	Developmental Delay	Developmental Delay Mild		Developmental Delay Moderate		Developmental Delay Severe		Developmental Delay Under Assessment
	Physical Disability	Physical Disability Mild		Physical Disability Moderate		Physical Disability Severe		Physical Disability Under Assessment
	Chronic Illness	Chronic Illness Mild		Chronic Illness Moderate		Chronic Illness Severe		Chronic Illness Under Assessment
	Learning Disability	Learning Disability Mild		Learning Disability Moderate		Learning Disability Severe		Learning Disability Under Assessment
	Visual Impairment	Visual Impairment Mild		Visual Impairment Moderate		Visual Impairment Severe		Visual Impairment Under Assessment
	Hearing Impairment	Hearing Impairment Mild		Hearing Impairment Moderate		Hearing Impairment Severe		Hearing Impairment Under Assessment
	Speech/Language Difficulties	Speech/Language Difficulties Mild		Speech/Language Difficulties Moderate		Speech/Language Difficulties Severe		Speech/Language Difficulties Under Assessment
	Behavioural/Emotive Difficulties	Behavioural/Emotive Difficulties Mild		Behavioural/Emotive Difficulties Moderate		Behavioural/Emotive Difficulties Severe		Behavioural/Emotive Difficulties Under Assessment
	Communication & Socialisation Difficulties	Communication & Socialisation Difficulties Mild		Communication & Socialisation Difficulties Moderate		Communication & Socialisation Difficulties Severe		Communication & Socialisation Difficulties Under Assessment
	Autistic Spectrum Disorder	Autistic Spectrum Disorder Mild		Autistic Spectrum Disorder Moderate		Autistic Spectrum Disorder Severe		Autistic Spectrum Disorder Under Assessment

	Who is your main health provider?:
	Aneurin Bevan University Health Board
	Other

	If other please specify:

	Do you or your child access/receive?
		Yes		No		Referral for
	Assessment Required	Assessment Required Yes		Assessment Required No		Assessment Required Referral for
	Social Worker	Social Worker Yes		Social Worker No		Social Worker Referral for
	SW for Sensory Impairment	SW for Sensory Impairment Yes		SW for Sensory Impairment No		SW for Sensory Impairment Referral for
	Domicillary Package	Domicillary Package Yes		Domicillary Package No		Domicillary Package Referral for
	Respite	Respite Yes		Respite No		Respite Referral for
	Direct Payments	Direct Payments Yes		Direct Payments No		Direct Payments Referral for

	Does your child receive?:
		Yes		No
	Special/Medical equipment/Aids	Special/Medical equipment/Aids Yes		Special/Medical equipment/Aids No
	Medical treatment/Medication	Medical treatment/Medication Yes		Medical treatment/Medication No
	Ongoing multi-disciplinary assessment	Ongoing multi-disciplinary assessment Yes		Ongoing multi-disciplinary assessment No
	Other personal help	Other personal help Yes		Other personal help No

	If other please specify:

	Does your child see any of the following?:
		Yes		No		Awaiting Appointment
	Physiotherapist	Physiotherapist Yes		Physiotherapist No		Physiotherapist Awaiting Appointment
	Speech Therapist	Speech Therapist Yes		Speech Therapist No		Speech Therapist Awaiting Appointment
	Occupational Therapist	Occupational Therapist Yes		Occupational Therapist No		Occupational Therapist Awaiting Appointment
	Specialist Health Visitor	Specialist Health Visitor Yes		Specialist Health Visitor No		Specialist Health Visitor Awaiting Appointment
	Orthoptist	Orthoptist Yes		Orthoptist No		Orthoptist Awaiting Appointment
	Audiologist	Audiologist Yes		Audiologist No		Audiologist Awaiting Appointment
	Clinical Psychologist	Clinical Psychologist Yes		Clinical Psychologist No		Clinical Psychologist Awaiting Appointment
	Child Psychiatrist	Child Psychiatrist Yes		Child Psychiatrist No		Child Psychiatrist Awaiting Appointment
	Community Paediatrician/Paediatric Nurse	Community Paediatrician/Paediatric Nurse Yes		Community Paediatrician/Paediatric Nurse No		Community Paediatrician/Paediatric Nurse Awaiting Appointment
	Hospital Consultant	Hospital Consultant Yes		Hospital Consultant No		Hospital Consultant Awaiting Appointment
	Dietician	Dietician Yes		Dietician No		Dietician Awaiting Appointment
	Other	Other Yes		Other No		Other Awaiting Appointment

	If other please specify

	Have you been offered/received a carers' assessment?
	Yes
	No

	How did you hear about the Index?
	Social Worker
	Health Visitor
	School
	Family Information Service
	Other

	If other please specify

Promise of Confidentiality:  The information provided is accessible to parent / child and designated members of your Local Authority’s Family Information Service and Child Health and Disability Team. It is designed to assist in planning services for children and young people with disabilities and additional needs.  Computerised information is stored securely and can only be accessed on a restricted basis. Information contained within this record is separate from other registers currently held by the authority, social services or local education authority.

Consent to Registration by submitting your response: ·I agree to my child's name being placed on The Index. This information will be treated confidentially. ·I understand I can withdraw my consent for my child's name to be placed on The Index ·I am in agreement for anonymised statistical information obtained on these forms to be shared with other professionals from Social Services, Health and Education for the purpose of planning and monitoring services. Please tick the option below to consent to the terms

I agree with the three points outlined above and consent to registration

If the above box is not ticked we cannot process the information in this response

Thank you for your registration, please click the submit button to send your response