Autism Assessment Referral Form

Please complete the form below in full if you wish to self refer your child for evidence based autism assessment as outlined by NICE (National Institute for Clinical Excellence) guidelines. This will then be passed to our Multidisciplinary triage team for review. Once triaged for assessment, you will be offered an appointment with details about the assessment to follow.

Patient Name *

First

Last

Date of Birth (DD/MM/YYYY) *

Langauge(s) spoken at home

Current School or Daycare Setting *

Patient Address (including postcode) *

Name of Next of Kin *

Next of Kin Contact Number *

Next of Kin Email address

Current Professional Involved *

For example: Speech and language therapist, Paediatrician, Educational Psychologist, CAMHS. Please include any confirmed diagnosis

Reason for Referral *

Please provide examples where possible, outlining the areas of developmental delay, communication skills, play skills, sensory concerns, behavioural concerns and social interaction skills

Has your child attended a formal assessment with the trust

If yes, please tell us which Healthcare Trust completed the assessment and what was the outcome?

Submit