Referral Form
This form should be completed by the professional requesting the assessment. Please note that all sections must be completed. An incomplete referral form may result in a delay in the referral being accepted.
The team will only be able to accept referrals that
meet the following criteria:
• Registered with a Scarborough, Whitby or Ryedale GP
•
Person is under 18 years
at the time of the referral.
•
Person is not at risk of harm to self
- being sufficiently stable to keep himself/herself safe throughout assessment, e.g., is not engaging in significant self-harm or attempts on own life. If person engages in significant self-harm or attempts on own life, acceptance of referral will only be considered if person has engaged with regular support and monitoring from local Child and Adolescent Mental Health team.
•
Person is not at risk of harming others
such that the assessor or other people accessing the service will be safe.
•
Person’s substances and/or alcohol
use is not at a level that may interfere with observational assessments/ability to engage in assessment process.
•
Person and family/carers have given fully informed consent
as indicated on the referral form.
•
Person shows clear difficulties in all areas that form the autism spectrum
as outlined below.
CHILD OR YOUNG PERSON’S DETAILS
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last Name:*
Preferred Name:
Date of Birth:*
Gender at Birth:*
Male
Female
Is gender the same as that assigned at birth:*
Please Select A Value...
Yes - the person's gender identity is the same as their gender assigned at birth
No - the person's gender identity is not the same as their gender assigned at birth
Not Known (not asked)
Not Stated (person asked but declined to provide a response)
Ethnicity:*
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Address Line 1:*
Town/City:*
County:*
Postcode:*
Mobile Number:*
Permission to leave voicemail on mobile number:*
Yes
No
Permission to send SMS:*
Yes
No
Home Number:*
Permission to leave voicemail on home number:*
Yes
No
Email:*
Language(s) spoken and understood (include sign language if relevant):*
Is an interpreter required to complete any communication with the family?
Yes
No
PARENT/CARERS’ DETAILS
Parent/Carer 1 full name:*
Relationship to person referred:*
Are the parent/carer address and contact details the same as the above?:*
Yes
No
Address (if different to the above):
Home phone number (if different to the above):
Permission to leave voicemail on home number:
Yes
No
Mobile phone number (if different to the above):
Permission to leave voicemail on mobile number:
Yes
No
Permission to send SMS:
Yes
No
Email address (if different to the above):
Parent/Carer 2 full name:
Parent/Carer 2 relationship and contact details (if different to the above):
Name and address of ALL Parents/Carers with legal parental responsibility (if different from above):
Have all persons with legal responsibility for the child given their consent for this referral? (THIS IS ESSENTIAL):*
Yes
No
Please list any other family members that you are happy for us to discuss this referral with including appointment reminders (Please provide, full name, address and contact numbers).
REASON FOR REFERRAL
TO BE COMPLETED JOINTLY WITH PARENT / CAREGIVERS AND REFERRER
Please explain why you are making this referral. The sections below are areas that we require information to decide if an autism assessment is needed. We have added examples that you might expect to see in a child that should be referred for an autism assessment. Please put a cross in the box next to any
examples
that apply and add any additional information that family/carer is giving.
1) Language and communication skills:*
Difficulties with language AND/OR takes language literally
Engages in little verbal communication
Repeats spoken language back verbatim
Talks ‘at’ people and little two-way conversations
Struggles to make eye contact or read facial expressions or to show facial expressions
No social chat, preference for talking about own specific interests
PLEASE DESCRIBE DIFFICULTIES WITH LANGUAGE AND COMMUNICATION FURTHER:*
2) Social interaction skills with others:*
Difficulties with making and keeping friends
Prefers being around adults
Takes little interest in other children
Tends to hang back and observe other children and/or struggles to approach peers
Shows interest in other children but doesn’t seem to know how to approach
Consistently approaches other children in a way that results in conflict/trouble
PLEASE DESCRIBE DIFFICULTIES WITH SOCIAL INTERACTION FURTHER:*
3) Interests and play skills:*
Shows little imaginative play
Tends to play on own
Struggles to engage in joint play AND/OR joint play often results in conflict
Dominates in play interactions (e.g., always needing to be in charge)
PLEASE DESCRIBE DIFFICULTIES WITH INTERESTS/PLAY FURTHER:*
4) Repetitive behaviour (motor, vocal or in their play/interests):*
Shows repetitive movement (flapping hands, spinning body repetitively, rocking body) or repetitive verbal utterances (repeating same phrases, sounds)
Engages in repetitive play (lining up toys, replaying same actions over and over)
Has highly specific interests that pursues to an extreme extent (including collecting information on particular topics)
Insists on certain routines (same cutlery/food items, any aspects of environment having to be certain way)
PLEASE DESCRIBE DIFFICULTIES WITH REPETITIVE BEHAVIOUR FURTHER:*
5) Ability to cope with change and transitions:*
Difficulties with transitioning between activities/settings – or requiring a lot of preparation and support from family/teachers/carers
Struggles to cope with unexpected changes/events
PLEASE DESCRIBE DIFFICULTIES WITH MANAGING CHANGE FURTHER:*
6) Sensory issues (over- or under-responsive to sounds, touch, etc):*
Responds with distress to auditory/visual stimuli
Appears distressed in busy environments
Dislikes being touched or seeks out excessive touch
Strong response to any stimuli (or lack of response)
PLEASE DESCRIBE ANY SENSORY DIFFERENCES FURTHER:*
7) Self-help skills and independence:*
Lack of independence in self-care
Difficulties with getting dressed/feeding
Other (please state):*
8) Behaviour (including any that is causing concern):*
Experiences periods of ‘meltdowns’, becoming overstimulated and shutting down
Extreme anxiety in social situations or new environments
Other (please state):*
Please list any diagnoses that have already been used to describe the child or young person’s difficulties and provide the date these were given if possible:*
Has the child/young person had an autism assessment before?:*
No
Yes
If yes, what date:
Are there any concerns about the child or young person’s mobility (including clumsiness)?:*
Are there any concerns about the child or young person’s vision or hearing?:*
Is the child or young person on any medication?:*
Yes
No
If yes, please specify and reasons for taking:
Does the child have any Learning needs? (e.g., require additional help at school for academic work):*
Does the child/young person have an Education and Health Care Plan (EHCP)?:*
No
Yes
Waiting / Currently being assessed
N/A
Who is the named SEND officer/contact for the EHCP:*
Have you discussed this referral with the child/young person, and have they agreed to it?:*
Yes
No
What are the thoughts of the young person about this referral? Please share their comments:*
Parental thoughts and hopes: what are they worried about and what would they like from the assessment?:*
Registered GP Practice and Health Information
GP Name:*
Address:*
Telephone Number:*
Please detail any concerns about the child’s health and well-being (including mental health):*
SCHOOL
Please detail any concerns about education (including additional support provided):*
School Contact Name:*
School Address:*
Telephone Number:*
REFERRER DETAILS
I have discussed the autism assessment pathway with the child/young person and family/carer(s), and they agree to be referred to and to be contacted by Be U North Yorkshire for an autism assessment:*
Yes
Referrer Name:*
Organisation Name:*
Address:*
Job Title:*
Telephone Number:*
Mobile Number:*
Email Address:*
PROFESSIONALS CURRENTLY INVOLVED
Please tick any currently involved:*
Health Visitor
Occupational Therapist
Social Worker
Paediatrician
Physiotherapist
Educational Psychologist
Clinical Psychologist
Psychiatrist
Speech & Language Therapist
CAMHS worker
Others, please list below
Please list any other professionals currently involved here:
Please give details of any professionals who have PREVIOUSLY been involved:*
Please send any reports you have available from the professionals above to beu.northyorkshire@nhs.net (the subject line must include the child's name).
Have CYP / Parents given consent to contact any of the professoinals above?:*
Yes
No
Are there any professionals the CYP / parents don’t want us to contact?:*
No
Yes
If yes, please specify:
SPECIAL REQUIREMENTS
Please give details below of any special requirements, e.g. Interpreter, Wheelchair Access etc:*
Privacy Statement
For the purposes of this form, Be U North Yorkshire (ABL Health) is the data controller responsible for the processing, storage and use of the data. If you have queries relating to how your data is handled, then please contact the relevant Administration Lead. Further details about how we handle your data, including the contact details of our Data Protection Officer, can be found in our Privacy Notice at: www.beunorthyorkshire.co.uk
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