Autism / ADHD Assessment Referral Form

Autism/ADHD Assessment Referral Form

Client Name

Name

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

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