Autism Assessment Referral Patient Name * First Name Last Name Date of Birth * MM DD YYYY Email * Contact Number * (###) ### #### Language(s) spoken at home * Current School or Daycare setting * Patient Address * Next of Kin Details Name of Next of Kin * Relationship to Patient * Contact Number * Email address * Referral Details Reason for Referral * Provide examples where possible of the following areas: developmental delay, communication skills, social interaction skills, play skills, sensory concerns, behavioural concerns Current Professionals Involved * Has your child attended a formal ASD assessment within the Trust? * Do you consent to any diagnosis for your child to be added to the child's digital record on the encompass system/NIECR to be seen by other professionals? * Yes No If your child receives a diagnosis of ASD, do you consent to the diagnosis being listed under their 'problem list' on their digital record on the encompass/NIECR system? * Yes No I consent access to be granted to the child’s electronic medical record prior to appointment * Yes Thank you! Your referral has been received and will be triaged by the ASD team to ensure appropriate. A member of the team will be in contact with you to discuss the next steps.
