ASD Pre-Referral Form under 16s

ASD Pre-Referral Form for under 16s

About the Child

Child's Name  Required
Date of Birth  Required
Address  Required
YesNo
Language delay
Hyperactivity/Attention Deficit Disorder (ADHD)
Hearing or visual difficulties
Autism Spectrum Condition, incl. Asperger’s Syndrome
Eating Disorder
Definitely AgreeSlightly AgreeSlightly DisagreeDefinitely DisagreeNot applicable to my child
1. They often notice small sounds when others do not
2. They usually concentrates more on the whole picture, rather than the small details
3. In a social group, they can easily keep track of several different people’s conversations
4. They find it easy to go back and forth between different activities
5. They don’t know how to keep a conversation going with their peers
6. They are good at social chit-chat
7. When they read a story, they finds it difficult to work out the character’s intentions or feelings
8. When they were in preschool, they used to enjoy playing games involving pretending with other children
9. They find it easy to work out what someone is thinking or feeling just by looking at their face
10. They find it hard to make new friends
11. They notice patterns in things all the time
12. They usually concentrate more on the whole picture, rather than the small details
13. In a social group, they can easily keep track of several different people’s conversations
14. If there is an interruption, they can switch back to what they was doing very quickly
15. They frequently find that they don’t know how to keep a conversation going
16. They are good at social chit-chat
17. When they were younger, they used to enjoy playing games involving pretending with other children
18. They find it difficult to imagine what it would be like to be someone else
19. They find social situations easy
20. They finds it hard to make new friends
Within the last 6 months6+ months agoNever
Have they self-harmed to a degree that has required treatment by a healthcare professional (e.g. stitches)?
Have they self-harmed by head banging, hair pulling, scratching, superficial cutting, or other ways that have not required medical attention?
Have they made an attempt to end their life?
Have they expressed thoughts about ending their life or that they would be better off dead?
Have they engaged in risky behaviour, e.g. use of drink and drugs, theft, or other criminal behaviour?
Have they harmed another person to the extent that that person has required treatment by a healthcare professional?
YesNo
Do they join in playing games with other children easily?
Do they come to you spontaneously for a chat?
Were they speaking by 2 years old?
Do they enjoy sports?
Is it important to them to fit in with their peer group?
Can they read appropriately for their age?
Do they appear to have an unusual memory for details?
Is their voice unusual e.g. overly adult, flat, or very monotonous?
Do they have persistent difficulties in social interactions? e.g. poor eye contact, extreme shyness and/or self-consciousness, avoiding social situations, high levels of anxiety in social situations?
Have teachers / health visitors ever expressed any concerns about their development?

Additional Information

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