ADULT ASD REFERRAL FORM

IMPORTANT INSTRUCTIONS

All sections must be fully completed and emailed to:

atrommindcare.adultASD@nhs.net

Before referring please note:

We are only able to accept referrals that meet the following criteria:

Ages 18years and above
AQ10 Score 6 and above and Presentation and experience indicative of Autism Spectrum Disorder and evidence of clinically significant impairment in functioning
No existing diagnosis of Learning Disability (As we are not commissioned to provide a diagnostic service for people with Learning Disabilities)
Patient has been stable in their mental health and where there is a history of alcohol/ illicit substance dependence- sober for at-least 6 months prior to referral.

PLEASE NOTE:

We are a diagnostic service only. We do not provide treatment or case or risk management after a diagnosis is made. It is expected that the GP and (Care-coordinator if applicable) would continue to have the overview of risk and treatment and they should be contacted if needed. We will of-course liaise with professionals following assessment as appropriate.
Assessment is undertaken by 2 Clinicians, will take place over multiple appointments and can take upto 3 hours in duration. Presence of patient’s parents / parental figures who can provide historical information on the patient’s childhood and development would be required for one of the sessions.

Referral Date*

Date

NHS Number*

Date of Birth*

Date

Name*

First NameLast Name

Full Postal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred telephone number*

Second telephone number

Gender*

MaleFemalePrefer not to sayOther

Ethnicity

Email*

Please note, your email address must be on an NHS domain (e.g. nhs.net).

Parent's name

First NameLast Name

Email

Please note, your email address must be on an NHS domain (e.g. nhs.net).

Preferred telephone number

Relationship to the patient

Referrer Name*

First NameLast Name

Referrer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Organisation*

Referrer’s ICB name*

Referrer’s Practice Code*

Role in organisation

Contact Number(s)

Email*

example@example.com

Has the patient consented to this referral?*

YesNo

Has patient consented to sharing their record data?*

YesNo

Has the patient consented to us contacting their parent/parental figure to participate in the assessment?*

YesNo

Any language barriers?

YesNo

If any language barriers is marked as yes, please give details as to what and how we could adjust for these:

GP Name*

First NameLast Name

GP Address*

GP’s ICB name*

GP’s Practice Code*

Contact Number(s):*

Email*

example@example.com

Reasons for Referral

Goal(s) of Referral

Has the patient completed AQ10 questionnaire?

YesNo

AQ10 Score

Any other risks (please provide details)

A Care Co-ordinator*

YesNo

If Yes, the provide name and contact details (email / phone number)

A Community Psychiatrist*

YesNo

If Yes, the provide name and contact details (email / phone number)

Social Services*

YesNo

If Yes, the provide name and contact details (email / phone number)

Probation Officer:*

YesNo

If Yes, the provide name and contact details (email / phone number)

Forensic services:*

YesNo

If Yes, the provide name and contact details of their key contact (email / phone number)

Substance misuse services:*

YesNo

If Yes, the provide name and contact details of their key contact (email / phone number)

Any children (living with patient) aged under 18 years?

YesNo

Current/previous history of domestic abuse/violence?

YesNo

Currently pregnant or up to 2 years post-partum?

YesNo

Subject to Leaving Care Provisions?

YesNo

Please provide any Relevant Medical, Psychiatric or Forensic history

Acute Medication (in the last 1 month)

RepeatMedication

Allergies & Sensitivities

Monitoring

	Date Last Measured	Result/Remark
Blood pressure
Pulse
Height
Weight
Blood Test

ADULT ASD REFERRAL FORM

PATIENT DETAILS

PATIENT'S PATENT'S DETAILS

REFERRER DETAILS

GP DETAILS

REASONS FOR REFERRAL

GOAL(S) OF REFERRAL

Please ask the patient to complete the AQ10 score which is a prerequisite. The link is on Atrom Mindcare website

SUMMARY OF RISK

Is there any ongoing involvement from:

RELEVANT MEDICAL, PSYCHIATRIC OR FORENSIC HISTORY

MEDICATIONS, ALLERGIES & MONITORING