Parents on the Autistic Spectrum Support Group
Referral Form
Parent name(s):Address:
Contact telephone numbers: / Mobile:
Home:
Work:
Email address:
Date of Birth and age:
Do you have an official diagnosis of Autism/Asperger’s Syndrome/other Autistic Spectrum condition (an official diagnosis from a Psychiatrist, Psychologist, paediatrician, etc)
If yes, please state when you were diagnosed and what with and by whom
If no, please state whether you are waiting for a diagnostic assessment to be completed
Number of children you have (please include their names and dates of birth):
Are you currently pregnant?
If yes, when is your due date?
Is this a self-referral?
If no, please give details:
Name of referrer and address/organisation:
Is the parent aware of this referral?
Do they give their consent to be referred? / Yes / No
Areas of need (tick all that apply):
¨ Asperger’s Syndrome/Autism
¨ Drug and alcohol misuse
¨ Anxiety/depression
¨ Other mental health issue
¨ Housing issues
¨ Financial difficulties
¨ Benefit advice
¨ Work and voluntary work
¨ Children’s school
¨ Childcare
¨ Family issues
¨ Physical health
¨ Advocacy
¨ Coping strategies
¨ Parenting skills
¨ Safety at home/in the community
¨ Other (please explain:______)
Please provide details of your current situation (For example: the situation at home; with regards to your child’s development/education/health, etc: your work status; any other issues)What support are you expecting to receive from PASS?
Are you currently in contact with Children and Family Safeguarding Services in any capacity?
If yes, please give details of the professional(s) working with you and the reason for their involvement:
Thank you for completing this form.
Please send all referrals to:
FAO Hannah Bridle - PASS
Asperger Social Care Team Or email it to:
Apsley One, Post Point 101
Brindley Way
Hemel Hempstead
Hertfordshire
HP3 9BF
How to find us:
South Hill Centre
Cemetery Hill
Hemel Hempstead
Hertfordshire
HP1 1JF
Every last Friday of the month, 12:30 until 2:30 (drop in)
1st session will be on 30th June 2017
South Hill Centre is easily accessible just five minutes from the bus station and town centre, where limited parking is available. The Watergardens car park is less than 100 metres away and has long and short term stay parking for 400+ cars. The centre is also easily accessible from either the M25 and M1. Hemel Hempstead railway station is on the main line from London Euston and is 20 minutes on foot or a short taxi ride.
The group will be held in the South Hill Centre’s crèche room which is fully kitted out with toys, baby and toddler activities and also baby changing facilities. You are encouraged, and more than welcome, to bring along your children if they are not in school/pre-school.
Refreshments are provided.
The group is held in a specially set up crèche room within the South Hill Centre, which has baby changing facilities, toys and other equipment. The centre also has disabled access.