Alternative contact number: address: Impact on life: Please rate the impact of your child/young person’s disability or additional need on their day to day life in the following areas. None or Low Medium High Area Not impact impact impact applicable Communication behaviour/interpersonal/social – skills Communication speech and language – Developmental delay Hand function Health chronic long term illness – Hearing Learning disability Mobility Personal care continence – Personal care eating/drinking – Personal care washing/dressing – Vision Please tick all boxes applicable to your child; if your child’s condition/diagnosis is not shown in the list below please use the box to provide details. ‘Other’ Disabilities Health Aspergers Syndrome Allergies / Anaphylaxis Autistic Spectrum Conditions Asthma Cerebral Palsy Diabetes Downs Syndrome Epilepsy Genetic Disability Gastrostomy Global Development Personal Care Hearing Impairment Tracheotomy Learning Disability Nasogastric feeds Physical Impairment O2 dependent Visual Impairment Additional Needs Assessment of educational needs ADHD Early Help Assessment (EHA) Education, Health and Care Plan Behaviour that challenges (EHC) Learning Difficulty Assessment Communication difficulties (LDA) Statement of Special Educational Dyslexia / dyspraxia Need Emotional behaviour difficulties None of these Learning Difficulties Sensory Difficulties Please provide more detail about your child’s condition including any dates of medical diagnosis
Alternative contact number: address: Impact on life: Please rate the impact of your child/young person’s disability or additional need on their day to day life in the following areas. Area Low impact Medium impact High impact None or Not applicable Communication – behaviour/interpersonal/social skills Communication – speech and language Developmental delay Hand function Health – chronic long term illness Hearing Learning disability Mobility Personal care – continence Personal care – eating/drinking Personal care – washing/dressing Vision Please tick all boxes applicable to your child; if your child’s condition/diagnosis is not shown in the list below please use the ‘Other’ box to provide details. Disabilities Health Aspergers Syndrome Allergies / Anaphylaxis Autistic Spectrum Conditions Asthma Cerebral Palsy Diabetes Downs Syndrome Epilepsy Genetic Disability Gastrostomy Global Development Personal Care Hearing Impairment Tracheotomy Learning Disability Nasogastric feeds Physical Impairment O2 dependent Visual Impairment Additional Needs Assessment of educational needs ADHD Early Help Assessment (EHA) Behaviour that challenges Education, Health and Care Plan (EHC) Communication difficulties Learning Difficulty Assessment (LDA) Dyslexia / dyspraxia Statement of Special Educational Need Emotional behaviour difficulties None of these Learning Difficulties Sensory Difficulties Please provide more detail about your child’s condition including any dates of medical diagnosis
disability_register_-_application_form_2017_2.docx