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ASD Pre-Referral Form 16+

ASD Pre-Referral Form for 16+

About You

Your Name Required

First Last

Date of Birth Required

Your Address Required

Street Address Postcode Country

Your Email Address Optional

Do you require any reasonable adjustments? Required

If yes, please elaborate Optional

Do you require a translator? Required

If yes, please elaborate Optional

Do you have any past or current mental health conditions? Required

If yes, please elaborate Optional

Do you have a carer? Required

If yes, please provide their name and contact number Optional

Answer all of the following questions: Required

	Definitely Agree	Slightly Agree	Slightly Disagree	Definitely Disagree
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

Do you have any sensory sensitivities? Required

Smell

Sounds

Taste

Light

Textures

None of the above

Do you have any of the following? Required

Difficulties forming and/or maintaining friendships with your peers

Difficulties with verbal communication e.g. conversations.

Difficulties with non-verbal communication (e.g., eye contact, facial expressions)

Difficulties regulating your emotions.

Intense interests which may be considered unusual in content and/or scope

Repetitive behaviours (e.g., “stimming”)

A resistance to change

None of the above

Answer all of the following questions: Required

	Within the last 6 months	6+ months ago	Never
Have you self-harmed to a degree that has required treatment by a healthcare professional (e.g. stitches)?
Have you self-harmed by head banging, hair pulling, scratching, superficial cutting, or other ways that have not required medical attention?
Have you made an attempt to end your life?
Have you expressed thoughts about ending your life or that you would be better off dead?
Have you engaged in risky behaviour, e.g. use of drink and drugs, theft, or other criminal behaviour?
Have you harmed another person to the extent that that person has required treatment by a healthcare professional?