Paediatric Autism Assessment Referral

Home Paediatric Autism Assessment Referral

"*" indicates required fields

Preferred Clinic Location

Patient Details

Name*

First Last

Date of Birth

Language(s) Spoken At Home

Current School or Daycare Setting*

Address*

Street Address City ZIP / Postal Code

Contact Number*

Next Of Kin Details

Name*

First Last

Relationship to Patient*

Contact Number*

Referral Details

Reasons for referral*

Provide examples where possible of the following areas: developmental delay, communication skills, social interaction skills,, sensory concerns, behavioural concerns

Is this a self funded or NHS trust funded referral?*

Self-Funded

NHS Trust Referral

Current Professionals Involved*

Include any confirmed diagnosis (e.g. SLT, OT, Paediatrician, Educational Psychologist, CAMHS.

Has your child attended a formal assessment of ASD within the Trust?

If so, when, which Trust and what was the outcome?

Do you consent to any diagnosis for your child to be added to the child's digital record on the encompass system to be seen by other professionals?

Yes

If your child receives a diagnosis of ASD, do you consent to the diagnosis being listed under their 'problem list' on their digital record on the encompass system?

Yes