Autism / ADHD Assessment Referral Form

Name of person being referred

Name

Surname

Date of Birth of person being referred

Preferred Pronouns

Which assessment are you requesting

Autism

ADHD

Name of Referrer and Relationship to Client

Contact Number

Email Address

Current School (if applicable)

Home Address

GP Name and Address

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

Organisational Skills / Executive Functioning

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