Please Ensure That the Information Contained in This Document Is Correct

Referral Form

Please ensure that the information contained in this document is correct.

It is very important that you complete all sections in asmuch detail as possible – the more information we have about somebody, the better we will be able to support them.All information within this referral form and enclosed documents will be the basis for the creation of an individual’s learning plan. It is therefore important the individual and support network (e.g. family) have involvement in providing this information.

All information will be kept confidential and stored in accordance with the Data Protection Act 1998, Equality and Diversity Act 2010 & The Freedom of Information Act 2000.

If you have any questions or would like any further information about any of our services please use the contact details below.

Has the individual consented to this referral? Y / N

Documents enclosed:

Diagnostic Reports Y / N

Risk Assessments Y / N

Transition Plans Y / N

Specialist Autism Services contact details

Specialist Autism Serviceshas sites in Bradford, Leeds, Shipley and York. Please return this completed referral form to the relevant site using the contact details below. Equallyif you require any further information please get in touch.

Bradford (Head office)
Merchants House
19 Peckover Street
Bradford
BD1 5BD

01274 789 798 / 778 888

/ Leeds
Great Northern House
Junction 7 Business Park
Stourton, Leeds
LS10 3DQ

01132 775 656

York
Millers Yard
2 & 4 Millers Yard
York
YO31 7EB

01274 789 798 / 778 888

/ Shipley (Autism First)*
The Old School
Wrose Brow Road
Shipley
BD18 2NT
01274 921 366

*Please note we have a separate referral form for Autism First – for more information please contact us on the above details.

Community Interest Company Registration No. 07030897

Please note that if this document has been printed or was received previously it may not be up to date. Please visit or contact one of our departments to ensure that you are completing an up to date version of this document.

Community Interest Company Registration No. 07030897

Contact and Emergency Contact Information

MembersName:
Preferred Name: / Home Phone No:
Mobile:
Address: Email:
Post Code:
Preferred method of contact: Cultural requirements:
DOB: / Date of Referral:
Emergency Contact:
Name: Relationship to Referee:
Home Phone: Work:
Mobile: Email:
GP’s Name- Address:
Phone: Email:
Current Prescribed Medication:
Name:
Dosage:
When taken:
Requires our support: Y / N / Name:
Dosage:
When taken:
Requires our support: Y / N / Name:
Dosage:
When taken:
Requires our support: Y/N
Epileptic Y / N (If Yes EMP) / Known Allergies:
Specific Dietary requirements: Y / N
Please state: / Allergies requiring medical intervention Y / N
(If Yes EMP)
Travel Arrangements:
(please note the referrer needs to arrange transport)
Independent traveller - Y / N
Taxi- Y / N
Taxi Name:
Telephone: / Living Arrangements:
Independent Y / N Supported Y / N
With Parents/Carers Y / N Other………………...
Respite Contact Details (If applicable)
Name:
Phone:
Social Worker/ CPN:
Name:
Phone:
Email: / Other Professionals involved in his/her care:
Name:
Role:
Phone:
Email:

Diagnostic Details

Does the individual have a diagnosis of an Autism Spectrum Condition? Y / N

What was the diagnosis given?
Where was the diagnosis obtained?
What was the date of the diagnosis?
Please detail any further information: / Please include a copy of the diagnosis report where possible

Has the individual been diagnosed with any other conditions/disabilities? Y / N

For example: Dyspraxia, Dyslexia, Irlen syndrome, Learning Disability, Physical Disability.

Please list condition/disability / How does this affect the individual? / Does the individual use any coping strategies/special aids?

Has the individual been diagnosed with any mental health conditions? Y / N

If yes, are they receiving support from their GP/CMHT? Y / N

Please list any mental health conditions / How does this affect the individual? / Does the individual use any coping strategies/special aids?

Does the person being referred have involvement from any other health services? Y / N

(e.g. Psychology, Occupational Therapy, Speech & Language Therapy.)

If YES, please specify name of team, nature of involvement and dates.

Social interaction, flexibility of thought and communication skills

Please tick the appropriate boxes from the list below. If you are unable to provide this information, please ask an appropriate person.

Social Interaction / Needs to develop / Maintaining with support / Independently
achieving
Forming relationships
Reciprocal social interaction
Understanding boundaries
Accept assistance
Response to praise
Response to constructive feedback
Behaves according to context of situation
Ability to compromise
Can engage in small group situations(up to 10 people)
Respects items
Flexibility of Thought / Needs to
develop / Maintaining
with support / Independently
achieving
Displaysempathy
Making appropriate choices
Transference of skills
Dealing with change
Dealing with the unexpected
Planning future activities
Appreciating others viewpoint
Awareness of consequences
Sense of humour
Recognition of right & wrong
Communication Skills / Needs to
develop / Maintaining
with support / Independently
achieving
Initiating conversation
Maintaining conversation
Turn taking
Variation in conversation
Responds to instructions
Responds to series of instructions
Interpretfacial expressions
Interpret literal language
Interpret body language
Speed of information processing

Sensory differences

Some individuals with an Autism Spectrum Condition have difficulty processing everyday sensory information. Individuals can be over sensitive (Hypersensitive) or under sensitive (Hyposensitive) or a combination of both.Sensory information is processed through our central nervous system - we organise, prioritise, understand and filter this information and then respond with thoughts, feelings and actions.

Individuals who have difficulties can experience irritation, stress, anxiety and even physical pain.Responses to different sensory information can affect individual’s behavior and daily choices which in turn affect their lives.Individuals who have sensory differences require support to identify how they process this information differently to others, coping strategies, changes to environmentand support to manage their anxiety levels.Collecting this information allows us to adjust our environments wherever possible to reduce any stress or anxiety caused by sensory differences.

Does the person being referred have any sensory differences? (If you don’t know this information please ask an appropriate person)

Senses / Over (Hyper) / Under (Hypo) / Impact / Coping Strategies
Sight
Sound
Touch
Taste
Smell
Balance
Body/spatial awareness
Synaesthesia

Risk Assessment– Please indicate the level of risk for each of the following areas:

Code / Areas of Potential Risk / High / Med / Low
1 / Risk of Self Neglect
2 / Neglect of Personal Hygiene
3 / Neglect of Personal Health
4 / Neglect of Home Environment
5 / Neglect of Financial Situation
6 / Risk of misuse of drugs and/or alcohol
7 / Harm through use of appliances (e.g. through tasks like cooking a meal)
9 / Preparing Hot Drinks
10 / Risk of Self Injury
11 / Physical Harm to Self through Self Harming
12 / Physical Harm through Travelling
13 / Risk of Abuse or Exploitation by Others
14 / Risk of Physical Abuse or Harm by Others
15 / Risk of Sexual Abuse or Exploitation by Others
16 / Risk of Institutional Abuse
17 / Risk of Neglect by Others
18 / Risk of Financial Abuse by Others
19 / Risk of Psychological Abuse/Emotional Abuse by Other
20 / Risk Related to a Physical Condition
21 / Risk of Isolation
22 / Risk of Violence or Harm to Others
23 / Risk of Physical Abuse or Harm to Others
24 / Risk of Sexual Abuse or Exploitation to Others
25 / Risk of Psychological Abuse/Emotional Abuse to Others
26 / Risk of Police intervention or crime

Risk assessment continued

Please list below areas of risk identified as high/medium above. / Please give a brief account to support this decision and any existing measures that are in place to reduce this risk. / Office use only:
Additional risk measures implemented by Specialist Autism Services.

Please note that if any high/medium risks are identified, our procedures require external risk assessments to have been provided prior to referral.

Are there any incidents of which we should be aware that may have caused any upset, distress or injury to the person being referred? Y / N

If yes please provide details:

Triggers, behaviours and coping strategies

Triggers – Situations or experiences that may cause upset, anger, stress, anxiety / What is the impact on the individual? e.g. behaviours and/or risk / Coping strategies or safety measures – Things that help the individual manage, cope or that reduce risky behaviours

Existing activities

Please give details of any other services, activities, placements, voluntary work or paid employment that the individual is doing at present (please include details of respite services accessed if applicable).

Morning / Afternoon / Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Community Interest Company Registration No. 07030897

Please list below details of past/ present Employment/ Work Placements/Experience
Place of Employment / Dates, from-to / Role/Experience
Please provide details of any difficulties/ support required
Please provide details of any work skills, abilities and interests
Please provide details about work goals or wishes (e.g. pursuing paid employment, voluntary work, education)

Employment

Any other information

Are there any other details regarding the person being referred that are important for us to know?

(e.g. preferred method of communication, specific habits or routines that can affect attendance)

Please provide any further information

Where did you find out about Specialist Autism Services?

e.g. internet search, word of mouth, an event

Communications and accessible information

Specialist Autism Services is committed to providing information to both members and parents/carers that is clear and accessible to all. We will always strive to ensure that any information sent out is accessible however if you require us to send information in an alternative format, please complete the below form.

Please note that this form is applicable to both parents/carers as well as members that are supported by Specialist Autism Services.

Adjustment to format(please tick or leave blank) / Parent/
carer / Member
I do not need any adjustments to information sent to me(standard format)(if ticked please skip to the bottom)
I need information to be sent in Braille
I need information in large print(please note by default SAS will send communications in font size 12)
I need information to be sent as an audio recording
I need information to be sent on coloured paper(please specify)
I need information to be translated to another language(please specify)
I need information to be sent in plain English (or jargon-free, with pictures)
I needanother adjustment to information sent to me (please specify)
Parent/
carer / Member
I require an advocate to speak on my behalf (for example to help me speak in meetings) (please tick or leave blank)

To be environmentally friendly, we prefer to circulate all information to and communicate with parents/carers via email wherever possible. Please write your email in the below box or indicate whether you would prefer to receive information in paper format/via post.

Email address:
I would prefer to receive information in paper format/via post(please tick)

Equality and diversity monitoring

Specialist Autism Services is committed to pursuing equality of opportunity. Monitoring our referral process is one way of helping to ensure that we do this. We would therefore be grateful if you would complete the questionnaire below. The information you give us will be treated as confidential, detached from your application and will only be used for monitoring and improving our policies and service provision.

I prefer to not take part in this monitoring process (Please tick)

1) Home environment

Lives independently / / Lives with parents/carers /
Shared care / / Lives in a care home /
Lives in supported accommodation (full time staff) / / Lives in supported accommodation (part-time staff) /
Homeless / / Other (please state) /

2) Age: how old are you? ❏ 20s ❏ 30s ❏ 40s ❏ 50s ❏ 60s ❏ 70s ❏ Other

❏ Prefer not to answer

3) Gender: ❏ Male ❏ Female ❏ Transgender ❏ Gender reassignment ❏ Prefer not to answer

4) Marital status: ❏ Married ❏ Single ❏ Divorced ❏ Separated ❏ Prefer not to answer

5) Sexual orientation:❏ Heterosexual ❏ Homosexual ❏ Bisexual ❏ Celibate ❏ Prefer not to answer

6) Do you consider yourself to have a disability? ❏ Yes ❏ No ❏ Prefer not to answer

7) What is your ethnic group?

White / Black/Black British
British / Black Caribbean
Irish / Black African
Any other White background / Any other Black background
Asian/Asian British / Mixed
Indian / White & Black Caribbean
Pakistani / White & Black African
Bangladeshi / White & Asian
Any other Asian background / Any other Black background
Other ethnic groups
Chinese / East European
Romani, Gypsy or traveller
Middle Eastern / / Other, please state:

8) Religion: Do you have a religion, and if so, what is it? ❏ Buddhist ❏ Christian ❏ Hindu ❏ Jewish ❏ Muslim ❏ Sikh❏ None ❏ Other Please state……………………………… ❏ Prefer not to answer

9) Have you been pregnant in the last 12 months? ❏ Yes ❏ No ❏ Prefer not to answer

Charges

Specialist Autism Services charges a for our Employment support, which has been calculated on an average of 52 weeks.

All invoices will be submitted on a calendar monthly basis. We must be in receipt of a contract before the individual starts our programme.

Please provide details of who to contact regarding payment:

Name:
Address:
Postcode:
Tel. No:
Email address:

Referrer’s details:

Name:
Job title (if applicable):
Address:
Postcode:
Tel. No:
Email address:

Referrer’s signature:Date:

Community Interest Company Registration No. 07030897