Adult ASD Assessment Self referral form Name * First Name Last Name Date of Birth * MM DD YYYY Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Contact number * Country (###) ### #### Language(s) spoken Current workplace/University Next of Kin Contact Number Country (###) ### #### Relationship to patient Reason for Referral * Provide examples where possible of any developmental Issues growing up, communication skills, social interaction skills, Sensory concerns, Behavioural concerns Current Professionals Involved ( if any) Have you attended a formal ASD assessment in the past? * If so please list when/where Do you consent to any diagnosis for you to be added to your digital health record on the encompass systems/NIECR to be seen by other professionals? * Yes No I consent access to be granted to my electronic medical record prior to appointments * Yes No Thank you! A member of our team will review your referral and get back to you as soon as possible
