Wufoo

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
Gender *
Male Female
Date of birth * DD / MM / YYYY
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.
Name of parent/carer * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Borough *
Home Phone
Mobile Phone
Email
What is the Diagnosis? *
When was the diagnosis received?
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.
Please explain the level of communication and favourite method of communication. (Speech/PECS etc)
Please explain the level of independence, including mobility, use of public transport.
Please explain the level of self-care skills, including asking for help, using the toilet, eating.
What is the reaction to group settings?
Which activities are most enjoyed?
Which activities are particularly stressful?
Most of our Services are on set times and days of the week, but it may be helpful to say which day of the week.time of day services would be most useful?

(please tick as many as you can)
Monday Tuesday Wednesday Thursday Friday Saturday Sunday ANY Mornings Afternoons Evenings ANY
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.
Saturday Play (over 8s) Sunday Play (over 8s) After School (over 12s) YNOT? (15-19s) Holiday Schemes (8-19s) Music Therapy Art Therapy Adult Art Group Adult Social Group Family Home Support (Reach Out)
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?
(This can be totally different to above)
How could we support you as a whole family?
Are there any other particular difficulties for your family?
Are there any practical issues with which you might like support?
Any other comments?
Referred by: First Last
Reason for referral:
Signed (your name will count as a signature) * First Last
Todays Date * DD / MM / YYYY
Do Not Fill This Out
Do Not Fill This Out

Wufoo

Referral Form for Services

Referred person's details

Family Details