ASD Referral Form
Please give sufficient detail under each section. Insufficient information may lead to the referral being rejected.
This form will be screened to establish the best course of action for this child’s needs.
Professional endorsement will be required for this referral e.g. SENDco , FSW, ASD Champion , or any other professional who knows the child well .
CHILD OR YOUNG PERSON BEING REFERRED
NHS No: / Address:Postcode:
Surname of Child/Young Person:
First Name/s:
Date of Birth: / Male
Female / Mobile No:
Home No:
DETAILS OF PARENT/CARER
Parent/Carer’s Full Name and Relationship to Child:
Is the parent happy to receive information electronically? Yes No
If yes, please provide email address:
Are they happy to receive text reminders on the provided mobile number? Yes No
/ HM Forces currently
Child In Care
Name & Address of additional person with legal parental responsibility (if different from above)
CONSENT
Ensure consent is obtained from the family for a Request and for sensitive information to be shared with professionals in the Early Help Hub. Please note anybody over 13 years, who is deemed competent, can give their own consent. This may be with or without parental consent.
By ticking this box, you are confirming that the following verbal consent has been given: “I agree to this referral and to my information being shared with agencies who are part of the Early Help Hub response”
Name of person giving consent ______Date ______
If you feel it is appropriate to submit this referral without consent from the young person, please contact the Early Help Hub to discuss this.
ETHNIC CATEGORY – Mandatory for Completion
British
Irish
Any other White background / White & Black Caribbean
White & Black African
White & Asian
Any other mixed backgrounds / Indian
Pakistani
Bangladeshi
Any other Asian background
Caribbean
African
Any other black background / Chinese
Any other categories
Not stated
EDUCATION DETAILS / DETAILS OF GP
Name and Address of School/Pre School/home school setting: / Name of GP and Practice Address:
PROFESSIONALS CURRENTLY INVOLVED WITH THE CHILD (please state details if known)
Speech and Language Therapy:
Paediatrician:
Occupational Therapy:
CAMHS:
Physiotherapy:
Educational Psychology:
Social Worker:
School Nurse:
Early years inclusion team (for example Portage, SENCO):
Others, please list:
PLEASE COMPLETE WITHAS MUCH DETAIL AS POSSIBLE
Development
Is there evidence of any development delays? Yes No
If yes, please specify:
Does the child have a statement of special educational needs (or EHC plan) or in the process of being assessed?
Yes No
Communication ability This could include difficulties with comprehension including literal interpretation, humour, sarcasm, Delay or absence of spoken language, Repetitive speech or echolalia (repeats words or phrases of others or from TV), Unusual characteristics of communication (i.e. accent, intonation, vocabulary), Impairment in non verbal communication (i.e. facial expressions, no gestures, no pointing, or waving by 12 months), Lack of, or prolonged eye contact, Inconsistent response to name
Please provide examples of the above
Quality of social interaction with family/peers/strangers Limited interest in typical play and/or play with peers, Unable to share interests or pleasures, Not responsive to other peoples facial expressions, feeling, lack of empathy, Lack of awareness of social norms (i.e. criticising teachers, unwillingness to cooperate, inability to follow current trends), Failure to relate normally to adults (too intense/no relationships)
Please provide examples of the above
Concerns regarding play/interests/behaviour Lack of pretend play, limited imagination, abnormal intense interests, unusual play, Difficulties with minor changes routine, Difficulties with minor changes of environment, Rituals that have to be performed
Please provide examples of the above
Sensory concerns: (e.g. overly sensitive or lack of response to touch, sound, vision, smell, taste, movement/balance)
Behaviour concerns: (e.g. poor sleep, dietary concerns, aggression/self-harm, danger awareness)
Hyperactivity
Does your child have trouble keeping his / her mind on work or playing for long?
Is your child overactive, restless or constantly moving?
Are they easily distracted and have difficulty concentrating?
Do they run and climb when they are not meant to?
Are they excitable / impulsive?
Please provide examples of the above checked boxes
Activities of daily living
Independence with personal care (e.g. toileting, washing, dressing, eating)
Organisational skills at home and school
Concerns with fine or gross motor skills
Please provide examples of the above checked boxes
Medical/additional needs: (to include co-morbid conditions and medication)
Educational concerns if known:
Please describe what strategies and interventions have been introduced to support this child/young person in school which have/have not worked
Is the child/young person supported by the school Autism Champion .
Parent/carer concerns:
What information and support has the parent accessed directly e.g. Family Support/Time out for ASD
What strategies have helped/not helped
WHAT ARE YOU AND THE FAMILY HOPING TO GAIN FROM THIS REFERRAL?
Please note that there is a waiting list for this pathway .
PERSON REFERRING
Referred by: / Address: / Tel:
Job Title: / Email: / Date of referral:
Please send completed forms to: email:
Telephone enquiries: 01872 322277 Monday to Thursday 8.45am to 5.15pm, Friday 8.45am to 4.45pm
Or visit the website www.cornwall.gov.uk/earlyhelphub