Referral Form

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The Autism Information and Advice Service Referral Form

Main Contact Details

This is the person we will contact regarding the referral

First Name *

Last Name

Email Address *

Phone *

Street Address *

City

County

Postcode

Country

Area *

If other, please tell us what area you are from *

Relation *

If other, what is your relation to the autistic person: *

Autistic Person's Details

Who is this referral about?

First Name *

Last Name

Date of Birth *

Does this person live at the same address as the main contact? *

Street Address *

City

County

Postcode

Does this person attend a school, college or alternative provision? *

What is the name of the school, college or alternative provison they attend? *

Is this person considered NEET (Not in Employment, Education or Training) *

Does this person know a referral is being made for support? *YesNo

Diagnosis

Details about the person's current or suspected diagnosis

Does this person have a confirmed diagnosis or diagnoses? *These are confirmed diagnosis by a mediacl professional

Please select all confirmed diagnosis *Please select all that apply.

If other please provide details *

Where these diagnosis a result of: *

What was the name of the provider who carried out the assessment? *

What is the suspected diagnosis or diagnoses? *Please select all that apply

If other please provide details *

What current stage of assessment is the person at? *

Further Information

Reason for Referral *Please include as much information about the support you require as possible and also include what support you have received in the past.

Consent *

By completing and submitting this referral form I agree for ASD Helping Hands to hold my details on their records to assist them with managing the support and communication they have with me. For more information on how we store and use your data please read our Privacy Policy.

ASD Helping Hands
Room 412-416, Breckland Business Centre
Dereham
Norfolk
NR19 1FD

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01362 685860
contact@asdhelpinghands.org.uk

Registered Charity Number: 1175729

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