Provide You with the Services You Need

Autism Service - Bucks
Self-Referral Form
/ Applicants (your) Full Name:
/ What we will do with your information:
We need to make sure that we understand your needs as much possible, so we may need to get more information from other people that know you.
All information we get will be treated as confidential and shared only with those who need to know. *Data Protection Statement below.
I understand and agree that;
I understand and agree that Connection Support may contact other agencies that work with me to get the information they need order for my application to be considered.
I also accept and agree that it may be necessary for Connection Support to contact other agencies who
work with me
I confirm that the information on this form is correct and I understand that providing
false information may lead to my application being declined

Signed (Applicant):
Print Name:
Date:
Data Protection and Privacy
Connection Support will keep your personal information safe. Sometimes we need to share this information in order to:

Provide you with the services you need
Keep you and others safe
Preventing and detecting crime

Please tell us about changes to your personal information as soon as possible so that we can keep your details up to date.
For more information please ask us.

Current address:

Date of birth:

Telephone/Contact details:

Email address:

Date of referral:

Are there any other people or agencies currently supporting you?
(Please provide name and contact details)
This could be a Social Worker, another Support Worker, a Connexions worker or someone else. /
Are you happy for us to contact these people if we need to as for more information?
Yes No

Monitoring our Services

We want to provide a service, which is fair and available to everyone. To help us monitor this, please answer the following questions.
Gender: /
Male  /
Female 
/ Do you consider yourself to have a disability? / 
Yes  / 
No 
Ethnic origin of applicant:
A – White /  British /  Irish /  Other
B – Mixed /  White & Black Caribbean /  White & Black African /  White & Black Asian /  Other
C – Asian or Asian British /  Indian /  Pakistani /  Bangladeshi /  Other
D – Black or Black British /  Caribbean /  African /  Other
E – Chinese or other Ethnic group /  Chinese /  Other
F – Gypsy / Romany / Irish Traveller 
Individual Requirements
Do you have any special needs that we need to know about that will help us during our assessment?
/ Communication / language barriers / 
Yes  / 
No 
Sensory Impairment
( difficulties with sight, hearing, speech) / 
Yes  / 
No 
Reading or writing / 
Yes  / 
No 
Disability/mobility / 
Yes  / 
No 
Please give details:

When we meet you are there any risks we should know about?

Have you ever been involved in or suffered from? / Yes / No / Don’t Know / Have you ever been involved in or suffered from? / Yes / No / Don’t Know
Violence or Aggression / Self Harm
Arson / Sex Offences
Domestic Abuse / Criminal Offences (other)
Substance / Alcohol use / Statutory Orders
Mental Health / Hazards from Others (friend/family/visitors)
Anything that triggers your behaviour? / Other (please specify)
Please give further details:
/ What’s your goal, how can we help?
What activities are you interested in?
Activity/ Support required / Details
/ What other things do you need help with?
Money, transport, life skills, meeting new people, cooking??
Or anything else??

Activity / Support required / Details

Has anyone helped you to complete this form?:

Yes No

If someone has helped you to complete this form – Please can they also provide their details:

Name (printed) :

Signature:

Their contact details:

Their Email address:

Are you happy for us to contact them for more information if required?

Yes No

Thank you for taking the time to complete this form.

Please return the form to:

Connection Support
Claydon House
1 Edison Road
Rabans Lane
Aylesbury
Bucks, HP19 8TE
Tel: 01296 484322 email: Fax : 01296 436542

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