Request referral for Autism Assessment

This form has been sent because we need more information to see if you/your child possibly autism. There are quite a few questions, so please make sure you have enough time to complete it. You can press the 'Save' button at the bottom of the form at any time.

Important: Please read carefully as the next steps may be delayed if the correct option is not chosen.

Autism is more related to social and behavioural problems. There are problems with interpreting and understanding the facial expressions and body language of others, and difficulty in social interactions and relationships. People might have very strong interests in particular subjects, which they can talk about at length, or struggle to have give and take in conversations. There is often a preoccupation with routine, or things being done a certain way. The inability to show flexibility may result in outbursts if these rigid behaviours are challenged.

Important: Important Information

More information on the request for right to choose referral for ADHD assessment.
It is important to read this before completing the assessment forms as you will need to specify your chosen provider in the form.

Request referral for Autism Assessment

Based on what is written here, do you think you might have:

Only specialists can make a diagnosis of Autism. If the information you provide suggests this might be the case, would you like to be referred to a specialist for further assessment?

Before we start, do you have a diagnosis of a learning disability?

Details of the person this form is about

Forename

Surname

Date of Birth

Post Code

Contact Telephone Number (mobile preferred)

Email Address

If you are filling in this form on behalf of someone else, please give your name, relationship and contact number.

Do you have a social worker?

Have you ever been under the care of a mental health (psychiatry) team?

Autism Spectrum Quotient (AQ)

I often notice small sounds when others do not

I usually concentrate more on the whole picture, rather than the small details

I find it easy to do more than one thing at once

If there is an interruption, I can switch back to what I was doing very quickly

I find it easy to 'read between the lines' when someone is talking to me

I know how to tell if someone listening to me is getting bored

When I'm reading a story I find it difficult to work out the characters' intentions

I like to collect information about categories of things (e.g. types of car, types of bird, types of train, types of plant etc)

I find it easy to work out what someone is thinking or feeling just by looking at their face

I find it difficult to work out people's intentions

Where would you like to be referred to?

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