Austism Referral form

Bio details

Name of young person *

Date of Birth *

Name of school *

Year Group *

Name of person completing the form *

Role *

Contact Number

Email Address *

Name of Parent/Carer/Responsible Individual completing the form *

Contact Number

Email Address *

Name of person funding the assessment *

Contact details

Date of referral *

Have parents/carers/responsible individual given their consent to a neurodiversity assessment? *YesNoPlease note that the referral cannot be processed without this consent

Diagnostic information

How long have you known the child/young person, and how long has this child/young person attended your setting? *

Describe the young person’s strengths and talents from first-hand experience of the young person? *

Has this young person been identified with Special Educational Needs? If so, in which areas? *

Provide details of the arrangements and resources currently allocated to address the young person’s needs and the impact these have made (please include hours of support if provided.) *

How would you describe the young person’s attention and concentration in learning and day to day tasks? (Include strategies used to maintain focus, turn-taking skills, ability to listen to others.) *

How would you describe the young person’s behaviour, both in school and at home? *

How would you describe the young person’s peer relationships, both in school and at home? *

How would you describe the young person’s communication skills with peers and adults? *

How would you describe the young person’s play skills and interests? (E.g. any repetitive behaviours, fixated interests, lining up of toys, difficulties in sharing, difficulties with collaborative play, any specific subject interests.) *

How would you describe the young person’s independence and organisational skills? *

Are you aware of any sensory processing difficulties? (E.g. over/ under sensitive to touch, taste, smell, sound, movement, vision, balance.) *

To what extent does the young person engage in school’s wider activities? *

Any additional information - please enclose any relevant documents e.g. young person passport, young persons targets on ILP/EHCP /provision map, reports/summaries from SALT, OT or other teams who are actively involved. *