Autism Spectrum Disorder (ASD) Referral Form



Referral Form for Suspected Autism Spectrum Disorder SECTION A TO BE COMPLETED BY REFERRERCHILD’s DETAILSFirst nameLast nameDate of birthAgeGenderNHS no.Your home address GP name & addressHome phone no.Mobile no.BIRTH PARENTS DETAILSFirst nameLast nameRelationship to childParental responsibility Yes No Address (if different from child)Your date of birth Contact email addressFirst nameLast nameRelationship to childParental responsibility Yes No Address (if different from child)Your date of birth Contact email addressOTHER CARERS/ PARENTS (continue on separate sheet if necessary)NameDate of BirthRelationship to childParental responsibility Yes No Address (if different from child)NameDate of BirthRelationship to childParental responsibility Yes No Address (if different from child address)SIBLINGS (continue on separate sheet if necessary)NameDate of BirthRelationship to childNameDate of BirthRelationship to childNameDate of BirthRelationship to child143192518859500SAFEGUARDINGIs the child in the care of the Local Authority or subject to a Court Order? Yes No If yes, please give details:Is the child the subject of a Child Protection Plan now or has been previously? Yes NoIf yes, please give details including name of social worker if current:REASON FOR REFERRALWhy are you making this referral at this time?For pre-school children, please summarise results of ASQ and ASQ: SE screening questionnaires (if relevant and if known):Please outline the child’s behaviours in the following areas:Communication:Interactions with peers and adults:Coping with change: Repetitive behaviour, interests and type of play activities: Concerns about gross or fine motor skills:Self-help, independence skills:Hearing:Vision:Please list any medical conditions, medications or mental health interventions:590740510033000Please include any relevant health information (which may include additional reports, screening questionnaires i.e. AQ {Autism Quotient} SCQ {Social Communication Questionnaire} ) REFERRER DETAILS AND DECLARATIONI have discussed my clinical concerns with the parents / carers and they have agreed to this referralReferrer name:Organisation:Job title:Telephone number:571563521463000PLEASE RETURN THIS FORM TO: Autism.enh-tr@ ................
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