Paediatric Autism Spectrum Disorder (ASD) Service

Paediatric Autism Spectrum Disorder (ASD) Service Referral Form Following a Diagnosis of ASD

The Paediatric ASD Service aims to provide and deliver support to children and young people with a diagnosis of ASD and their families.

Referral Criteria:

 The child or young person must be age 2-18 years (19 years if attending special school), resident within the Northern Trust geographical area and have a diagnosis of ASD: (This diagnosis should have been received from an HSC Trust or relevant Health Authority in another geographical area).  The child or young person referred has been identified as being in need of support as a result of having a diagnosis of ASD.  The child or young person requires ASD specific support different from what core Health and Social services and Education services can offer.  The person with parental responsibility is in agreement to this referral being made.

What the Paediatric ASD Service aims to offer individuals and their families may include:

 Family support delivered in partnership with Autism NI which aims to support parents/carers following a diagnosis with help, advice, a listening ear or signposting to relevant services and support groups.

 ASD parent education programme for parents/carers whose child/young person has received a diagnosis of ASD. This programme aims to develop parents/carers knowledge & skills in managing their child/young person’s development.

 A meeting with parents/cares to identify the child/young person’s needs with the aim of: 1. Providing practical advice and support in relation to ASD concerns and 2. Making onward referrals if appropriate. 3. Identifying further support programmes in relation to specific issues/concerns.

 Joint planning with health & education professionals

Child/Young Person’s Details Name: DOB/CA:

1 Address: H&C Number:

Postcode: School/Nursery:

Diagnosis: Autism Date of Diagnosis (if known):

Aspergers Co-morbid conditions (e.g. Epilepsy, ADHD): GP: GP Address/Tel No:

Person with Parental Responsibility Name: Relationship: Address (if different to child): Telephone Numbers  Home: Postcode:  Work:  Mobile: Email address: Language(s) spoken at home (including BSL):

Is an interpreter required for parent and/or child? Yes No

If yes, which language:

Does the person with parental responsibility understand written English?

Yes No Don’t know

Professionals Involved Please tick and state name if known Health visitor SLT

Paediatrician OT

CAMHS Educational Psychologist

Physio Autism NI/NAS/Autism Initiatives (list):

Social Worker Other (list):

Child Protection Register Is the child on the Child Protection Register? Yes No

Is the child a Looked After Child? Yes No

Is the child a Child in Need? Yes No Please Provide Information:

REASON FOR REFERRAL TO ASD INTERVENTION SERVICE

2 In order for us to determine the most suitable intervention for the child/young person, please state the child/young person’s difficulties under the relevant headings below Parent/carers’ and young persons’ (if appropriate) understanding of ASD Behaviour

Communication Skills

Emotional (e.g. anxiety/anger)

Toileting

Sensory

Social Interaction

Daily Routine/Activities

Other Difficulties

What do you feel this service could offer?

Referrer Declaration

I have discussed my clinical concerns with the person with parental responsibility as well as young person if aged 16 or above and they have agreed to this referral. They consent to this

3 referral being discussed by the service which include professionals from the paediatric ASD intervention team (NHSCT) and support officers (Autism NI & NAS) Or I hold parental responsibility for the child being referred and I consent to this referral being discussed by the service which include professionals from the paediatric ASD intervention team (NHSCT) and support officers (Autism NI & NAS)

Referrer Details Name:

Profession:

Address:

Telephone Number:

Signed: Date:

PLEASE RETURN COMPLETED FORM TO:

Paediatric Autism Spectrum Disorder (ASD) Service The Cottage 5 Greenmount Avenue Ballymena BT43 6DA

Tel: 028 2563 3777 E-mail: [email protected]