About the person being referred

This referral form is the first step in our assessment process. Please answer with as much detail and as many examples as you can.

Name of person being referred

First name

Last name

Date of Birth of person being referred

Preferred Pronouns

Which assessment

Which assessment are you requesting

Autism

ADHD (available for 6-18 year olds only)

Referrer and contact details

So we know who to reply to.

Name of Referrer and Relationship to Client

Contact Number

Email Address

Address, school and GP

Current School (if applicable)

Home Address

GP Name and Address

Waiting lists and diagnoses

On Trust waiting list for:

Autism

ADHD

Please list any relevant, confirmed, diagnoses (e.g. Autism, OCD, Tourette's, ADHD, etc.)

Communication, friendships and behaviour

Please give as many details and examples as necessary.

Please comment on the following, giving as many details and examples as necessary:

Communication and Interaction Skills

Friendships

Behaviour / Emotions

Sensory differences (e.g. response to noise, touch, taste, smell etc)

Interests, routines and attention

Please give as many details and examples as necessary.

Special interests

Repetitive movements or noises

Response to change

Attention and Concentration

Organisational Skills / Executive Functioning

Review your answers

Please check everything below before submitting. You can go back and change any section — nothing is lost.

Form submitted

Your reference

Autism / ADHD Assessment Referral Form