ASD Referral - Paediatric

Autism Assessment Referral - Paediatric

Preferred Clinic Location

Preferred Location *

Patient Details

Patient Name * Date of Birth * Language(s) Spoken At Home Current School or Daycare Setting * Patient Address * Contact Number * Patient Email

Next Of Kin Details

Name of Next Of Kin * Relationship to Patient * Contact Number * Email Address

Referral Details

Reasons for referral *

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

Current Professionals Involved * Has your child attended a formal assessment of ASD within the Trust? 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

I consent access to be granted to the child’s electronic medical record prior to appointment

Captcha *

* Required