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If NO . What are the indications that the person has an autistic spectrum disorder ? E.G. Difficulties in communication, interaction, flexible thinking, routines, sensory issues .
What is the Referral requesting ? Please include . Presenting issues . Any recent changes . Behavioural difficulties
N.B. If the Referral is for Training this should be Booked through the Training Department or Consortium at Festival Hall . Please contact them directly for availability, and to Book dates .
Are there any special considerations in relation to the person’s autism that need to be made when making contact and considering assessment ? E.G. Time of the day, venue, who to contact .
G.P. Doctor . Name & Address
Any other agencies involved
Is the Service User aware of this Referral
Address as above . Via Referred by
Date of Referral
Does the person have a diagnosed learning disability ? Did they attend a special school or unit ? Are ( or have ) they ever been supported by a Learning Disability Service ?
Does the Service User live with family / supported / adult placement etc ?
Date Of Birth
Electronic Mail Account
Who is the Care Provider
Team / Agency
Does the person have a diagnosis of an autistic spectrum disorder ?
If YES . When was this given and by whom ?
( If known )