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

Referred by

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 ?

Name

Date Of Birth

Address

Telephone Number

Electronic Mail Account

Ethnic Origin

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 )