Please complete the Child/ Younger Person Autism Referral below. This will be sent on to our Secretaries for processing.

Process for assessment of Autism Spectrum Disorder

This form is only to be completed by patients who have received a direct text message link from our Secretaries.

If you have not received a text link, your form will not be processed. 

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CHILD/ YOUNG PERSON'S DETAILS
 
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CONSENT
 
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PARENT/ CARER DETAILS

Parent/ Guardian 1.

Parent/ Guardian 2.

 
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ASSESSMENT INFORMATION
Please refer to the attached appendix for examples 
Appendix
Please refer to the attached appendix for examples
Please refer to the attached appendix for examples
Please refer to the attached appendix for examples

Professionals involved (please tick):

 
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CONFIRMATION

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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