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Referral Form for Services

RfA provides services to support individuals and families with an autistic spectrum condition. In order for us to offer you the most appropriate service please fill in this form. We will only share this Information with others with your permission unless there is a serious concern that you, your child or someone else described in the form is at risk of harm. Please complete as much of the form as possible.

If English is not your first language or you need help filling in the form for any other reason then please let us know and we will help you.

NB. Sections with a red star are compulsory.

Referred person's details

This section is for information about the person with autism spectrum condition.
Name * First Last
Date of birth * DD / MM / YYYY
Parent/Carer Name * Title First Last Suffix
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
London Borough/City Council/Local Authority. *
Home Phone
Mobile Phone
Email
Ethnicity

Please tick the one that best describes the referred person - this is for monitoring purposes only, to ensure our services are reaching everyone in our community.
Do you need an interpreter?
If yes what language do you speak?
Gender *
Male Female
Referred by (if other than family): First Last
Referrers phone number if different
Referrers Email if different
Please state which School/Centre is currently attended.
Please list any services currently received
Please list any services for which you are currently on the waiting list.
Diagnosis *
Autism Asperger's ADHD Moderate Learning Difficulty Severe Learning Difficulty OCD Mental Health Issues (i.e. depression) Other Sibling (please go straight to activities section)
If 'other' diagnosis please add here
Preferred methods of communication
Verbal speech only Verbal assisted by PECS and symbols Verbal assisted by Makaton Verbal assisted by Signalong Verbal assisted by pointing and leading Verbal persistant questioning Non-verbal assisted by PECS an symbols Non-verbal assisted by Makaton Non-verbal assisted by Signalong Non-verbal assisted by vocalisation (noises) Non-verbal assisted by pointing and leading Non-verbal
If other method of communication please state below:
Barriers to communication
Echolalia/repetative language Metaphorical language Monologue Not understanding others Elective mutism
Displays anxiety by:
Self-harming behaviour Absconding Shouting/swearing Physical attack Withdrawal
Level of Independence
Needs adult support at all times Needs support on public transport Can travel independently Other
If other please describe below:
Level of self-care skills
Needs support with all self-care In pads or nappies Needs reminders for the toilet Needs help to dress Needs help with feeding On toilet training programme Other
What is reaction to group settings?
Once settled is at ease in most groups Once settled is at ease in small groups Finds groups difficult Is very unhappy in a group setting Other
What activities are most enjoyed?
Music Dancing Swimming Computer/IT Outdoor games Playing with specific toys/objects Arts and crafts including photography Reading Board games Outings and trips Park/playground Horse riding/animals Other
Practical Service Options:
Although we will talk through all the possibilities with you, if you already have a particular preference for a service then please let us know by ticking the boxes.
This does not guarantee you this service, but will help us when we talk to you.
Play under 8 Play 8 - 12 After School (over 12s) Youth Clubs (15-19s) Holiday Schemes (8-19s) Music Therapy Art Therapy Adult Groups Family Home Support (Reach Out) One to one paid support (direct payment/personal budget)
Family Details

This section is for information about the family or carers of the person with autism spectrum condition.
Siblings?
Please list name and age of siblings
Other important family members/key friends
Which would you say are the main areas of stress for parent/carer/family?
Any other comments?
Signed (your name will count as a signature) * First Last
Todays Date * DD / MM / YYYY
Do Not Fill This Out

Wufoo

Referred person's details

Family Details