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Referral for an autism spectrum disorder (ASD) assessment

Referral for an autism spectrum disorder (ASD) assessment

Pronoun:
Preferred communication:
Contact consent:
Ethnicity:
Gender identity:
Gender identity same at birth?
Do you have a carer?

Carer details (if applicable)

Relationship to patient:
Preferred communication:
Contact consent:
Make primary contact?

Risk – Have you:

Self-harmed to a degree that has required treatment by a healthcare professional (e.g., stitches)?
Self-harmed by head banging, hair pulling, scratching, superficial cutting, or other ways that have not required medical attention?
Tried to end your life?
Expressed thoughts about ending your life or that you would be better off dead?
Engaged in risky behaviour, e.g., use of drink and drugs, theft, or other criminal behaviour?
Harmed another person to the extent that person has required treatment by a healthcare professional?

For local mental health support and guidance, please see our mental health information page.

Get advice from 111 or ask for an urgent GP appointment if:

  • you need urgent help for your mental health

Get help from 111 online or call 111 and select the mental health option.

Alternatively, you can contact the practice during opening times.

Call 999 or go to A&E now if:

  • someone’s life is at risk – for example, they have seriously injured themselves or taken an overdose
  • you do not feel you can keep yourself or someone else safe

A mental health emergency should be taken as seriously as a physical one. You will not be wasting anyone’s time.

Call 999.

Do you show significant signs of the following?
Please select all that apply.

AQ-10

For each statement, please select the option that best suits you.

I often notice small sounds when others do not.
I usually concentrate more on the whole picture, rather than the small details.
I find it easy to do more than one thing at once.
If there is an interruption, I can switch back to what I was doing very quickly.
I find it easy to ‘read between the lines’ when someone is talking to me.
I know how to tell if someone listening to me is getting bored.
When I’m reading a story I find it difficult to work out the characters’ intentions.
I like to collect information about categories of things (e.g. types of car, types of bird, types of train, types of plant etc).
I find it easy to work out what someone is thinking or feeling just by looking at their face.
I find it difficult to work out people’s intentions.

Supporting information

Please attach any relevant clinical correspondence and reports – important information includes:

  • Current/past assessment reports (Neurodevelopmental, OT, SLT, school report, further education, work etc.)
  • Copies of reports from previous involvement with CAMHS

Maximum file size: 67.11MB

Additional needs

Do you need a British Sign Language (BSL) interpreter?
Do you need step-free access or a ground floor consulting room?
Do you require an interpreter?
Do you have a hearing impairment?
Do you have a visual impairment?
Consent
Terms and conditions
Location