Umbrella Referral Form - January 2020

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Children, Young People and Families Service Delivery Unit

Umbrella Pathway
Covercroft Centre
Colman Road
Droitwich
Worcestershire
WR9 8QU
Tel: 01905 681047/01905 681056
Email: WHCNHS.CommPaedsSCP@nhs.net
Umbrella Pathway Assessment Criteria
The Umbrella Pathway is an assessment process for children and young people whose
difficulties could be explained by an Autism Spectrum Disorder (ASD).
Service referral criteria are in place to ensure that this service works with the child/young people
and their families who need and will benefit from further highly specialist assessment.
For all children
1. The referral must be discussed and agreed with parents/carers.

2. The child/young person must be of school age (up to the age of 18) for an Autism
assessment
3. The child/young person must be registered with a Worcestershire GP.
For child/young person with difficulties that may indicate an ASD
1. There needs to be evidence of significant difficulties, impacting on their daily lives, across
the 4 areas of their development associated with ASD: Social emotional reciprocity, Non-
verbal communicative behaviours, Developing and maintaining relationships and Restricted
patterns of behaviour.
2. The referral must include evidence that an Early Help or graduated approach response has
been considered and implemented over time in relation to the presenting difficulties and the
needs of the child, rather than an assumption that ASD is the cause. This must be in place
and evidenced over a minimum of 6 months or 2 terms for all school aged children. This
graduated response could be from e.g. Specialist Educational Services, Paediatrician,
Speech and Language Therapy, Occupational Therapy, CAMHS, etc. The evidence needs
to tell us the outcomes of the support put in place.
3. Parents/carers and professionals need to work in partnership to complete the referral form
so that we understand how the child/young person presents at home and at school. In a
school setting the form should be completed and signed by the school ASD Lead or SENCo.
If no problems are being seen in school we will still need the school view.
Chairman: Chris Burdon

Chief Executive: Sarah Dugan Helping you live well
Umbrella Pathway
Neuro-Developmental
Assessment and Care
Guidance notes
The referral form requires very detailed information and is best given to parents to complete in
partnership with a child’s school/setting or professionals working closely with the child over time
on a regular basis.
It is not unusual for children to present differently at home and at school and it is important that
we know about these differences. If a child is not experiencing as many difficulties in the
setting/school as at home we would like school and parents to meet and monitor the difficulties
over 2 terms so that the referral is supported with information that documents and helps us
understand these differences.
The information sent to us will be considered at our multi agency referral meeting which is held
monthly and is attended by representatives from the Umbrella Pathway Team. Further
information or clarification may be requested at that stage. When the information has been
considered we will inform parents, referrers and professionals involved of our
recommendations.
A re-referral of children previously assessed by the Service cannot be accepted within an 18

month period and there will need to be evidence of significant changes in the child’s
presentation since the previous assessment was carried out before a re-referral is made.
We require a wide range of detailed information to decide if this is the most appropriate service
for a child or young person. The information provided forms part of the child/young person’s
assessment if they are accepted.
The Umbrella Referral consists of the following 4 parts and all parts need to be completed in full
before the referral can be considered:-
1. Umbrella Pathway referral form 

2. Age appropriate consent form 
3. Questionnaire completed by parent 
4. Questionnaire completed by Educational setting. 
Also include evidence as detailed above. 

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Part 1: UMBRELLA PATHWAY REFERRAL FORM

Surname: Address:
Forenames:
Preferred Name:
Contact No:
DOB: Sex: M/F
Ethnicity: Email:
Educational Placement: EHCP/Statement Is child a LAC or in a foster placement? Yes/No

in place
Yes/No If yes, provide name and contact details of Social
Worker:
GP details:
Contact No:
Email:
Person with Parental Responsibility:
Please Print Name:
Name of Referrer: (print and sign)
Designation:
Address/Base:
Contact No:Email:
Date:
Services Involved: Please tick if appropriate
Behaviour Support Service Learning Support Service

CAMHS Team Occupational Therapist
CCN/Autism Team School Nurse
Clinical Psychologist Social care
Community Paediatrician Speech & Language Therapist
Health Visitor Other (please specify)
Educational Psychologist

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Information about the Child/Young Person’s Communication and Behaviour
Do you suspect: Attention and Concentration Difficulties? Yes No

Social Communication Difficulties? Yes No
Attachment Difficulties? Yes No
Speech and Language Difficulties? Yes No
Learning Difficulties? Yes No
Tics? Yes No
Other Yes No
Please give further details as this will help with our assessment:
Current diagnosis/labels (including when any diagnosis was made and by whom, if known):
Current Medication:
Please highlight areas of significant concern/difficulty below.
The referral WILL NOT be accepted without evidence of difficulties in each

of these areas.
Socio-emotional reciprocity
Reciprocal interaction, awareness of other people, interest in other people, seeking comfort, awareness of
other people’s feelings, understanding social rules, showing empathy, giving comfort, turn taking, and
inappropriate behaviour.
Give detail and describe the impact of these difficulties on the child/young person’s function:

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Non-verbal communication
Poorly integrated verbal and nonverbal communication, abnormalities in eye contact/body
language/gestures/facial expressions/intonation.
Relationships
Adjusting behaviour for different contexts, sharing imaginative play, making friends, and interest in peers.
Inflexibility
 Stereotyped or repetitive motor movements, use of objects or speech.
 Insistence on sameness, inflexible adherence to routines, ritualised patterns of verbal or nonverbal
behaviour, difficulties with creativity/imagination.
 Highly restricted, fixated interests that are abnormal in intensity or focus.
 Sensory differences or unusual interest in sensory aspects of the environment.
Describe the impact of these difficulties on the child/young person at home/school:
Please provide any additional information that may be helpful to support this referral:

Umbrella Pathway
Neuro-Developmental
Assessment and Care

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Part 2: CONSENT FORM FOR CHILD/YOUNG PERSON (UNDER 16)

Child’s Name: - NHS Number: - DOB:
The Neuro-Developmental Assessment process may involve any of the following:
Paediatric Assessment Placement observation/assessment

Speech and Language assessment Paediatric Occupational Therapy assessment
Developmental interview Psychological assessment
Psychiatry assessment Home assessment
Following assessment, the Umbrella Pathway team will discuss the information available and a decision regarding
diagnosis will be agreed.
Ye No Please give your consent for the following:

s
  For my child to be assessed and discussed by the Umbrella Pathway Team
  For any relevant information about my child to be requested and shared between health, education/nursery
placement and social services professionals as appropriate. This will include sending copies of written
reports.
  For the relevant professionals to visit my child’s placement setting to carry out assessments and offer advice
to the staff.
  For any relevant support linked with the process to be carried out by relevant professionals, including on-
going support and intervention following the Umbrella process (by Umbrella related professionals/teams).
  For students to observe and participate in assessment and intervention. This will always be under the
supervision of the professional involved.
  Audio records may be taken as part of my child’s assessment and intervention.
  For information to be shared with my child’s other parent. If no, please state why below:
………………………………………………………………………………………………………………………….
(please be aware that if there are no contentious issues or safeguarding concerns, the Umbrella
Team will be obliged to share information with both parents)
Details of person providing consent:
Sign::…………………………………….……………………..Print Name:…………………………………………………………
Relationship with child:…………………………………………………Date:……………………………………………

Under the Children’s Act 1989 certain people hold ‘parental responsibility’ for a child. This may include the child’s mother; the father if
the parents are married at the time; the father if he has acquired responsibility by a court order or by a document in a proper legal form
agreed by the mother; adoptive parents; others who have acquired parental responsibility through legal systems e.g. residence order,
parental responsibility order.
Please let us know your preferred method of feedback following assessment:
Clinic Appointment Telephone Call Email (Please note this is not a secure link)
Contact No: Email:

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Please provide address details for parents living together:
Additional Information about parents living separately:
We would be most grateful if parents who live separately could complete the following additional
information.
We are aware that this can be a sensitive issue, but it is important that both parents should have the opportunity to
be involved in the Umbrella process, if they wish and will both need to complete a parental questionnaire
If one parent is no longer involved in the child’s life, please write ‘No recent involvement’ in the appropriate box
below.
MOTHER FATHER
Name: Name:
Address: Address:
Telephone number: Telephone number:
Frequency of contact: Frequency of contact:

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Part 2: CONSENT FORM FOR YOUNG PERSON (16+ self-consent)
Name: NHS Number: DOB:
The Neuro-Developmental Assessment process may involve any of the following:
Paediatric Assessment Placement observation/assessment

Speech and Language assessment Paediatric Occupational Therapy assessment
Developmental interview Psychological assessment
Psychiatry assessment Home assessment
Following assessment, the Umbrella Pathway team will discuss the information available and a decision regarding
diagnosis will be agreed.
Yes No Please give your consent and agreement for the following:
  To be assessed and discussed by the Umbrella Pathway Team
  For any relevant information about me to be requested and shared between health, education, and social
services professionals as appropriate. This will include sending copies of written reports.
  For the relevant professionals to visit my placement setting to carry out assessments and offer advice to the
staff.
  For any relevant supported linked with the process to be carried out by relevant professionals, including on-
going support and intervention following the Umbrella process (by Umbrella related professionals/teams).
  For information to be shared with parents/guardians – (if yes please complete next page)
  For students to observe and participate in assessment and intervention. This will always be under the
supervision of the professional involved.
  Audio records may be taken as part of my assessment and intervention.
Sign::…………………………………….…………………………Date:……………………………………………
Under the Children’s Act 1989 certain people hold ‘parental responsibility’ for a child. This may include the child’s mother; the father if the parents
are married at the time; the father if he has acquired responsibility by a court order or by a document in a proper legal form agreed by the mother;
adoptive parents; others who have acquired parental responsibility through legal systems e.g. residence order, parental responsibility order.
Please let us know your preferred method of feedback following assessment:
Clinic Appointment Telephone Call Email (Please note this is not a secure link)
Contact No:________________________________________________________ Email:______________________________________________________

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Please provide address details for parents living together:
Additional Information about parents living separately:
We would be most grateful if parents who live separately could complete the following additional
information.
We are aware that this can be a sensitive issue, but it is important that both parents should have the opportunity to
be involved in the Umbrella process, if they wish and will both need to complete a parental questionnaire
If one parent is no longer involved in the child’s life, please write ‘No recent involvement’ in the appropriate box
below.
MOTHER FATHER
Name: Name:
Address: Address:
Telephone number: Telephone number:
Frequency of contact: Frequency of contact:

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Part 3: INFORMATION FROM PARENTS/CARERS
Name of child: DOB:

Education Placement:
Tell us about your child’s strengths. What are they good at?
Tell us about any concerns you have regarding your child’s social communication:
Please comment and give examples where appropriate on the following areas of current
functioning for your child:
Socio-emotional reciprocity:
Can you have a two-way conversation with your child on a variety of topics?
................................................................................................................................................................
Give examples of situations where your child has talked with you just to participate in some form of
conversation, however simple.
…………………………………………………………………………………………………………………..
………………………………………………………………………………………………………….............
Does your child share his/her interests with you?
………………………………………………………………………………………………………….............
Do they share in your interests?
………………………………………………………………………………………………………….............
How would you describe your child’s ability to understand others thoughts and feelings? Give examples
of how your child has sought comfort from others.
………………………………………………………………………………………………………….............
Give examples of your child offering comfort to another person.
………………………………………………………………………………………………………….............

Umbrella Pathway
Neuro-Developmental
Assessment and Care
………………………………………………………………………………………………………….............
Give examples of when your child has referred to their own or others feelings.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Does your child seek help? How do they do this?
………………………………………………………………………………………………………….............
Would your child give unprompted clarification if you misunderstood them? Give examples.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Non-verbal communication:
Please tell us about your child’s use of eye contact.
………………………………………………………………………………………………………….............
Please tell us about other aspects of your child’s non-verbal communication, such as gesture, body
posture and facial expression.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Comment on your child’s tone and volume of voice.
………………………………………………………………………………………………………….............
Relationships:
Describe any interactions with peers. Does your child appear to enjoy the company of his/her peers?
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
If your child plays with toys please describe how they play with them.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Will your child share and play with their toys with other children? Give examples.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
If your child no longer plays with toys, how did they play with toys on their own and with other children in
the past?
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Also comment on your child’s use of imagination in play and creative writing.
………………………………………………………………………………………………………….............
Describe any friendships your child has and the nature of the friendship.
………………………………………………………………………………………………………….............
Give examples of unusual ways in which your child may behave in different situations e.g. restaurants,
when people come to your house or with familiar family members.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Use of language:
Was your child’s speech delayed from an early age? Give detail and if you have had any information
from assessments please include these.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Give examples of things your child has pointed to, to show you recently e.g. a book or their
surroundings. Does he/she co-ordinate this with eye gaze?
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Does your child understand humour? Give examples
………………………………………………………………………………………………………….............

Umbrella Pathway
Neuro-Developmental
Assessment and Care
………………………………………………………………………………………………………….............
Does your child understand non-literal language? Give examples.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Give examples of any words your child has made up.
………………………………………………………………………………………………………….............
Stereotypical movements:
Does your child ever show unusual, repetitive behaviours in the following areas? Give examples.
Body movements ……………………………………………………………………………………………..
Use of objects…………………………………………………………………………………………...……..
Repeated use of speech……………………………………………………………………………...………
Inflexibility:
Describe any things that your child has to do in a particular way or order e.g. routines or rituals.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Explain how they cope with change or manage new activities.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Interests:
List any of your child’s hobbies or interests that are unusual in their intensity or type.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Describe how this intensity is demonstrated and how it is different from any other interest that they have.
………………………………………………………………………………………………………….............

Umbrella Pathway
Neuro-Developmental
Assessment and Care
………………………………………………………………………………………………………….............
Sensory/Motor
Describe any hypersensitivity towards light, sound, touch, taste or textures.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Is he/she insensitive or overly sensitive to noise, heat or pain? Give details.
………………………………………………………………………………………………………….............
Please can you give any examples of unusual sensory interests, such as playing with textures and
chewing.
………………………………………………………………………………………………………….............
………………………………………………………………………………………………………….............
Is he/she independent with their self-care and organisation? Give details.
………………………………………………………………………………………………………….............
Are there any concerns regarding motor skill development? Give details.
………………………………………………………………………………………………………….............
Comment on any difficulties in the following areas: - Give detailed information
Dressing/undressing……………………………………………………………………………………….....
………………………………………………………………………………………………………….............
Use of buttons/zips…………………………………………………………………………………………….
………………………………………………………………………………………..…………………………
Using cutlery……………………………………………………………………………………………………
…………………………………………………………………………………………………………………..
Handwriting………………………………………………………...…………………………………………..
………………………………………………………………………………………………………….............
Using scissors………………………………….………………………………………………………………

Umbrella Pathway
Neuro-Developmental
Assessment and Care
………………………………………………..…………………………………………………………………
Bike riding………………………………………………...…………………………………………………….
………………………………………………………………………………………………………….............
Your comments and contributions are very much valued. Thank you for taking the time to fill in
this questionnaire.
Completed by: …………………………………………Relationship to child:………………………
Signed:………………………………………………… Date:………………………………………..

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Part 4: INFORMATION FROM EDUCATION PLACEMENT
Please note: This information will form part of the final Umbrella Pathway Report and
will be shared with parents/carers and other professionals.
Name of child: DOB:

School: Year Group:
SEND (please delete as applicable): None/ SEND support*/ EHCP**

*Please attach a copy of the last two IEPs (or similar) for the child
**Please attach a copy of the EHCP
Is the child known to a Speech and Language Therapy team? Yes No If Yes, please
provide copies of reports
Date of initial involvement: Date of review:
Has school made a referral to an Educational Psychologist? Yes No If Yes, please

provide copies of reports
Date of initial involvement: Date of review
Has school made a referral to the CCN Team? Yes No If Yes, please provide copies
of reports
Date of initial involvement: Date of review
Please indicate this child’s age related expectations with their learning:
Maths Significantly Above/Above/At Expected/Below/Significantly Below
Writing Significantly Above/Above/At Expected/Below/Significantly Below
Reading Significantly Above/Above/At Expected/Below/Significantly Below
Please give detail of this child’s strengths at school
Please give detail of this child’s needs at school

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Please comment on the following areas of functioning in school and describe how you have
responded to each area of concern and the difference your intervention has made
SOCIO-EMOTIONAL RECIPROCITY
Concern Observations (please detail examples in school and the

Y/N child’s strengths and/ or difficulties)
Participation in two-way
conversation on a variety of topics
Participation in some form of

conversation, however simple
Providing appropriate amounts of

detail in conversation compared to
peers (e.g. too much/too little)
Frequent unexpected changes of

topic when talking
Changes in style of language

between children and adults at a
similar level to others in the class
(e.g. more polite with adults)
Inappropriate behaviour when

interacting with peers or adults
Sharing interests with others
Sharing others’ interests
Ability to understand others’

thoughts and feelings
Offering comfort to another person
Referring to their own or others

feelings
Seeking comfort from others
Seeking help from others
Providing unprompted clarification if

he/she was misunderstood

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Interventions put in place (if concerns in this area).
Impact and progress following intervention.
NON-VERBAL COMMUNICATION
Use of eye contact
Other aspects of non-verbal

communication, such as gesture,
body posture and facial expression.
Tone and volume of voice
RELATIONSHIPS
Interaction with and enjoyment of

company of peers.
Nature of play with toys (if

appropriate)
Sharing and play with toys with

other children
Use of imagination in play and

creative writing (including
participation in drama, art, and other
creative activities).
Existence and quality of friendships.

Umbrella Pathway
Neuro-Developmental
Assessment and Care
LANGUAGE
Experiencing language difficulties in

school
Understanding and following verbal

instructions at a similar level to
others in the class
Requiring additional explanations

compared to most in the class?
Active participation in class

discussions when compared to most
in the class
Ability to make predictions and give

explanations at a similar level to
others in the class
Understanding or using vocabulary
Learning and using abstract

concepts taught within the
curriculum
Use of unusually technical or

advanced vocabulary

Umbrella Pathway
Neuro-Developmental
Assessment and Care
STEREOTYPED MOVEMENTS
Unusual, repetitive behaviours in the

following areas:
a) Body movements
b) Use of objects
c) Repeated use of speech
INFLEXIBILITY
Activities or routines carried out in a

particular way or order e.g. rituals.
Ability to cope with change or

manage new activities.
INTERESTS
Hobbies or interests that appear

unusual in their intensity or type.
SENSORY
Hypersensitivity towards light,

sound, touch, taste, or textures.
Insensitivity or oversensitivity to
noise, heat or pain.
Unusual sensory interests, such as

playing with textures and chewing.
Independence with their self-care

and organisation.
Motor skill development

Umbrella Pathway
Neuro-Developmental
Assessment and Care
Fine motor skills in the following

areas:
a) Dressing/undressing
b) Handwriting
C) Using equipment (e.g. scissors)
Please make any additional comments that you feel may be relevant to our assessment:
Person completing form (Print name)

…………………………………………………………………………………………………………………
Signed:……………………………………………………………..Date……………………………………………
What is your relationship with this child? (i.e. class teacher/teaching assistant)
………………………………………………………………………………………………………………………………………
How long have you known this child.............................................................................................................


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Umbrella Pathway

Children, Young People and Families Service Delivery Unit

Tel: 01905 681047/01905 681056

Umbrella Pathway Assessment Criteria

For all children

1. The referral must be discussed and agreed with parents/carers.

For child/young person with difficulties that may indicate an ASD

Chairman: Chris Burdon

A re-referral of children previously assessed by the Service cannot be accepted within an 18

1. Umbrella Pathway referral form 

Also include evidence as detailed above. 

Chairman: Chris Burdon

Part 1: UMBRELLA PATHWAY REFERRAL FORM

Educational Placement: EHCP/Statement Is child a LAC or in a foster placement? Yes/No

Please Print Name:

Name of Referrer: (print and sign)

Services Involved: Please tick if appropriate

Behaviour Support Service Learning Support Service

Chairman: Chris Burdon

Information about the Child/Young Person’s Communication and Behaviour

Do you suspect: Attention and Concentration Difficulties? Yes No

Please highlight areas of significant concern/difficulty below.

The referral WILL NOT be accepted without evidence of difficulties in each

Chairman: Chris Burdon

Describe the impact of these difficulties on the child/young person at home/school:

Chairman: Chris Burdon

Chairman: Chris Burdon

Part 2: CONSENT FORM FOR CHILD/YOUNG PERSON (UNDER 16)

The Neuro-Developmental Assessment process may involve any of the following:

Paediatric Assessment Placement observation/assessment

Ye No Please give your consent for the following:

  Audio records may be taken as part of my child’s assessment and intervention.

Details of person providing consent:

Relationship with child:…………………………………………………Date:……………………………………………

Please let us know your preferred method of feedback following assessment:

Contact No: Email:

Chairman: Chris Burdon

Please provide address details for parents living together:

Additional Information about parents living separately:

Telephone number: Telephone number:

Frequency of contact: Frequency of contact:

Chairman: Chris Burdon

Part 2: CONSENT FORM FOR YOUNG PERSON (16+ self-consent)

Name: NHS Number: DOB:

The Neuro-Developmental Assessment process may involve any of the following:

Paediatric Assessment Placement observation/assessment

  To be assessed and discussed by the Umbrella Pathway Team

  Audio records may be taken as part of my assessment and intervention.

Please let us know your preferred method of feedback following assessment:

Contact No:________________________________________________________ Email:______________________________________________________

Chairman: Chris Burdon

Please provide address details for parents living together:

Additional Information about parents living separately:

Telephone number: Telephone number:

Frequency of contact: Frequency of contact:

Chairman: Chris Burdon

Part 3: INFORMATION FROM PARENTS/CARERS

Name of child: DOB:

Contact No:__ Email: