Professional’s Observational Report Form 
To be attached to the Referral to the
Developmental Paediatric Service
This form should be filled in by nursery, pre-school, or school. If the child does not attend an educational setting, but is known to a professional, please ask this professional to complete this.  For example, Speech Therapist, Health Visitor, GP, Childminder, community nursery nurse, Specialist Early Education Service (SEES) Worker, Family Centre staff member. 
If you are the parent/carer, please give this form to your child’s nursery, pre-school, school or a professional (as above) to complete based on that professional’s observations of your child.
If there is no professional who knows your child, please contact your health visitor service who should be able to support you with getting this completed. 
Please note that if the completed forms are not returned, this referral will be discharged.

Please let us know if you have difficulty with this. 0300 247 0025 Option 4 or email scfh.contact@hcrgcaregroup.com 
Child Name:	DOB:	
Home Address:

	Name of Nursery/School:

Tel No. of Nursery/School:	
Address of Nursery/Pre-school/school:

	Name of Key Worker/Person and SENCo:	
Is this child on: (please tick appropriate box)

Setting/School Support   

Specialist Support   

Early Intervention Funding  

Being considered for an assessment of educational needs 

	Other agencies involved: please list agencies and names where known (e.g. Early Years SEND Advisors, Educational Psychology, SEES team, Speech and Language Therapy, Occupational Therapy, Physiotherapy, Surrey Autism Outreach Team, STIPS team).

If given consent by the family, please share any relevant reports from other agencies.

	
Start date at Pre-school/Nursery/School:

	Days/Hours attending:	

General Health and Past Medical History	
If known, please comment on birth history, any history of illness or relevant family history if known. 

	

Communication and Language	
Does the child have any expressive language difficulties? (e.g. limited vocabulary, not talking in certain situations, struggling to form phrases and ideas in a logical way?)

If the child is verbal, do they talk in an unusual way? (e.g. high or odd pitch, flat or robotic, more exaggerated than normal)

Does the child copy speech? This could be copied directly from others or TV. Please give an example if possible. 

Does the child refer to themselves in the 3rd person? (e.g. “Sue is hungry”, instead of “I am hungry”, or referring to themselves as “you”, “she” or “he”?)

Is the child’s speech unusually formal or do they sound older than expected for their age? (e.g., large range of vocabulary) 

Does the child struggle to communicate their needs? This could include learning/emotional/practical needs. Please give examples. 

Does the child talk mainly about their own topics of interest? Please give examples. 

Any other comments regarding the child’s communication skills?

	

Physical Development	
What activities are chosen/avoided? Comment on skills displayed in coordination and movement, how does the child explore/access the environment? Is anything preventing him/her accessing the environment/curriculum? Does the child ever display any repetitive body movements?

	
Personal, Emotional and Social Development	
Please include details about the child’s overall level of self-care (feeding self, utensil use, drinking, toileting, undressing and dressing Inc. Coat and shoes).
Comment on the child’s sense of themselves and others in general (see further questions below for specific areas)

	
Social Interaction	
Does the child have any difficulties when playing with other children? (e.g. disruptive, lack of understanding, would rather play alone)

Does the child not seem to follow setting norms? (e.g. not following the classroom setting routine, no interest in peer/group activities, unwilling to cooperate with the setting environment)

In social situations, does the child seem to become overwhelmed, overstimulated or withdrawn? Please give examples. 

Does the child appear to interact with adults in an unusual way? E.g., prefers adult company, develops relationships with adults easier than children, becomes too attached to adults. 

Does the child become upset when other people are in their personal space? 

Does the child become upset if they are unable to complete a task, or if they feel they are being rushed?

Does the child struggle to use non-verbal means of communication? E.g. lack of eye contact, no use of gestures. 

 	
Play skills/Imagination
	
Does the child struggle to play imaginatively? (e.g. they only use objects for their intended function/don’t create stories or don’t use dolls/action figures/animals to make stories/play scenarios?)

Does the child show any repetitive play behaviours? (e.g. lining things up, dropping the same things from a height, doing the same sequence of events)

	
Attention and concentration/focus	
Please list any concerns about attention (to child and/or adult-led tasks activity levels or impulsive behaviours:

	
Learning levels	
Please list relevant information surrounding learning needs or concerns regarding current academic achievement or progress:

	
Flexible behaviour	
Does the child have difficulties in managing unstructured places? (e.g. PE hall, playground, off timetable classroom days)

Does the child have difficulties managing change? (e.g. new supply teachers, school celebrations or school trips) How does the child react to unplanned change?

	
Other Factors	
Does the child have any unusual responses to sensory stimuli? (e.g. textures, smells, taste, loud noises, light?) Please give examples. 

Does the child have any unusually intense interest or knowledge in specific areas or an unusual topic?

	
Preschool/Nursery/School Concerns	
Please list your current concerns about the child and the support they may need:

	
Preschool/Nursery/School Support already in place 	
Please list the support you currently have in place to support the child, what is working well, and what you have tried that has not worked:

	
Other information	
Please include additional relevant information:

	

Name:
Signed:		
Job Title:		
Date of Completion:	
	
To help this referral be processed efficiently, please upload this simultaneously with the referral via the Surrey Child and Family Health One Stop online portal:
https://referral.surreychildandfamily.co.uk/form 
For any queries about this process or using the portal please call 0300 247 0025 Option 4 or email scfh.contact@hcrgcaregroup.com