<p>Date Received: …………………………………………. LCID Logged: ………………………………. ASD ref number …………………………………</p><p>Health and Care Number ...... </p><p>PAEDIATRIC AUTISM SPECTRUM DISORDER (ASD) SERVICE REFERRAL FORM Please complete form in BLOCK CAPITALS, PLEASE NOTE that completion of this form implies parental consent has been obtained for referral to the service and for the service to contact any relevant agencies within Health and Education - All sections must be completed Child’s Name: DOB: Address: Post Code: Parent/Guardian Name: Relationship: Address: Post Code: (if different from child) Tel No: Home: Work: Mobile: E-mail address: </p><p>Language(s) spoken at home (including BSL): Is an interpreter required for parent and/or child? Yes No Which language(s)? Does the Parent/Guardian understand written English? Yes No Don’t Know</p><p>GP: Tel No: Surgery Address: ------School/Nursery: Tel No: Address: </p><p>Professionals currently involved with the child? Please indicate, and advise name (if known) Health Visitor SLT Paediatrician OT CAMHS Educational Psychologist Physiotherapist MASTS Social Worker Others, please list: </p><p>Is the child on Child Protection Register? Yes No Is the child a looked after child? Yes No Is the child a child in need? Yes No</p><p>Please provide information:</p><p>Version 2 – april 14 Why are you making a referral at this time?</p><p>Are the parents in agreement with your concerns?</p><p>Not in Agreement Share Concerns Total Agreement</p><p>Please state specific concerns under the following headings: (An attached report is sufficient if it covers the following areas)</p><p>Development: Is there evidence of any developmental delay? Yes No Does the child have a statement of special educational needs? Yes No If yes, please specify:</p><p>Communication ability: (e.g. Level of understanding/expressive language; non verbal communication; unusual characteristics of communication)</p><p>Quality of social interaction with family / peers / strangers:</p><p>Concerns re: play / interests / leisure activities:</p><p>Activities of daily living: (e.g. degree of independence, awareness of danger)</p><p>Behavioural concerns: (e.g. poor sleep; dietary concerns; aggression/self harm; obsessive behaviours; coping with change)</p><p>Version 2 – april 14 Medical / additional needs: (to include co-morbid conditions and medication)</p><p>Other information:</p><p>Referred by:</p><p>Name: </p><p>Address: </p><p>Tel No: </p><p>Profession: </p><p>Signature: ______Date: ______</p><p>Please return completed form to:</p><p>Paediatric Autism Spectrum Disorder (ASD) Service The Cottage 5 Greenmount Avenue Ballymena BT43 6DA</p><p>Tel: 028 2563 3777 E-mail: [email protected] </p><p>Version 2 – april 14</p>