Asperger Syndrome Team Referral Form

*PLEASE NOTE*

  • In order to be eligible for support from Balance Asperger Syndrome Team, an individual must already have a diagnosis.
  • Evidence of the diagnosis must accompany this referral; this may be the diagnostic report or a letter from the individual’s GP.
  • Please complete all sections of this form otherwise the referral will not be accepted.

Details of the person being referred

Name:

Has this person consented to this referral? : Yes No

Address:

Landline phone: Mobile phone:
OK to leave a voicemail message?YesNo

Email address:

Date of Birth: . Gender:.

GP Name:.

GP Address:

Does the person have a personal budget? Yes No Unsure

Gender:

Referrer Information

Name of referrer:. Telephone:.

Job Title:. Email:

Agency:. Date of Referral:.

Reason for Referral

Please describe the main reason/reasons for referral.

The Asperger Syndrome Team offers support in the following areas. Please tick the type/s of support you feel will be of benefit to the individual you are referring to the service.

The Team Leader will agree a programme of support at the initial assessment.

Preparing for work
In employment support
Understanding Asperger Syndrome
Communication and social skills
Housing options / applications
Independence living skills
Benefit options / applications
Education options / applications
Independence with personal finance
Social Group – runs approximately every 4-6 weeks
Drop-in Groups (two groups) – run every week

Please add any other information you feel is useful to this referral

Are you aware of any risks involved with the person being referred? If so please detail below (For example, aggressive behaviour, self harm, suicidal ideation / attempts, substance misuse etc.)

Thank you for taking the time to complete this referral.

Please post it to the below address or to with accompanying evidence of diagnosis.

Balance Asperger Syndrome Team, Hollyfield House, Hollyfield Road, Surbiton KT5 9AL

020 3468 3080