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Autism / ADHD Assessment Referral Form
Autism/ADHD Assessment Referral Form
Client Name
*
Client Name
Name
Name
Surname
Surname
Date of Birth
*
Preferred Pronouns
*
Name of Referrer and Relationship to Client
*
Contact Number
*
Email Address
*
Current School (if applicable)
Home Address
*
GP Name and Address
*
Main Reasons for Referral
On Trust waiting list for:
Autism
ADHD
Please comment briefly on the following:
Communication and Interaction Skills
Friendships
Behaviour / Emotions
Sensory differences (e.g. response to noise, touch, taste, smell etc)
Special interests
Repetitive movements or noises
Response to change
Attention and Concentration
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