Hounslow Adult Autism Assessment and Diagnostic Service

SELF-REFERRAL FORM

Hounslow Adult Autism Assessment and Diagnostic Service

Tel: 0208 583 4410

Referralsvia HRCH Single Point of Access should be sent to:

E-mail:

Tel:020 8630 3943

Fax: 020 8630 3639

Personal Details:

Family name: / First name: / Title:
Date of Birth: / Gender:
Home address:
Tel/Contact no: / Post code:
NHS no (if known):
Self-defined Ethnicity:
What is your first language?
Do you require an interpreter?
yes no / Do you require any assistance to communicate?
GP’s name:
Address:
Tel/Contact no: / Post code:
Are you currently receiving support from any professional agencies, such as social work or education? If yes, please give details:
What is your current accommodation? (e.g. living alone, with spouse/partner, family/carers)
What is your marital status?
Reason for referral – what are the main concerns that have led you to seek an assessment for Autism Spectrum Condition? (Further details can be given on the next page.)

Specific Concerns related to ASC - please completeto the best of your knowledge:

Development –Were there delays in your early development, such as in learning to speak? Please give details.
Social functioning – Do you feel that you have significant difficulty interacting with others, such as your family, peers, or strangers? Do you find it difficult to communicate with others? Please give details.
Interests/leisure activities – Do you have particular interests or activities to which you dedicate a large amount of your time? Please give details.
Daily living- How independently are you able to live? Do you require assistance with daily living tasks, such as cooking, cleaning, going out in the community, or managing your finances?
Emotional well-being – How would you describe your mood in recent weeks? Have you often felt very sad, anxious, stressed, or angry? Please give details.
Mental health – Have you previously been diagnosed with a mental health problem? Do you have any concerns about your mental health at present? Please give details.

Information about Risk

Do you believe that you might be at risk of harm from others, or may be at risk of causing harm to yourself or others? Have there been concerns about this in the past? If yes to either of these questions, please give details.

Where applicable/available, please include any additional documents that might relate to this referral, including previous psychological or psychiatric reports, or educational statements.

Please also complete and include the Autism Quotient (AQ-10), given on the next page

AQ-10

Autism Spectrum Quotient (AQ)

This form should be completed by the person being referred. Please include this with your referral.

Please tick one option per question only: / Definitely Agree / Slightly Agree / Slightly Disagree / Definitely Disagree
1 / I often notice small sounds when others do not
2 / I usually concentrate more on the whole picture, rather than the small details.
3 / I find it easy to do more than one thing at once.
4 / If there is an interruption, I can switch back to what I was doing very quickly.
5 / I find it easy to ‘read between the lines’ when someone is talking to me.
6 / I know how to tell if someone listening to me is getting bored.
7 / When I’m reading a story I find it difficult to work out the character’s intentions.
8 / I like to collect information about categories of things (e.g. types of car, types of bird, types of train, types of plant etc)
9 / I find it easy to work out what someone is thinking or feeling just by looking at their face.
10 / I find it difficult to work out people’s intentions.