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Autism / ADHD Assessment Referral Form
Autism/ADHD Assessment Referral Form
Name of person being referred
*
Name of person being referred
Name
Name
Surname
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
*
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
Organisational Skills / Executive Functioning
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