Hounslow Adult Autism Assessment and Diagnostic Service

Third Party Referral Form

Hounslow Adult Autism Assessment and Diagnostic Service

Tel: 0208 583 4410

Referrals via HRCH Single Point of Access should be sent to:

E-mail:

Tel:020 8630 3943

Fax: 020 8630 3639

Family name: / First name: / Title:
Date of Birth: / Gender:
Home address:
Tel/Contact no: / Post code:
IAS no (if known): / NHS no (if known):
Ethnicity:
Any other ethnic group (please specify):
First language spoken:
Interpreter required?
yes no / Communication style (e.g. verbally fluent, phrased speech, Makaton):
GP’s name:
Address:
Tel/Contact no: / Post code:
Please give details of any services currently involved:
What is the person’s current accommodation? SELECT FROM DROP DOWNLiving aloneLiving with spouse/partnerLiving with parents/carersSupported accommodationResidential careLiving in shared priviate accommodation
What is the person’s marital status? SELECT FROM DROP DOWNSingleMarriedLong-term partnerDivorcedWidowedUnknown
Is Client aware of referral? Yes No / Date of referral:
Referrer’s name: / Referrer’s role/job:
SELECT FROM DROP DOWNKeyworkerPaid CarerFamily CarerAdvocateDay Centre StaffDay Centre ManagerHospital DoctorHospital NurseHospital TherapistPALS OfficerGPCommunity Healthcare ProfessionalMental Health WorkerCPNPsychiatristCTPLD - Community NurseCTPLD - Care Manager/Social WorkerCTPLD - PsychiatristCTPLD - PsychologistCTPLD - PhysiotherapistCTPLD - DieticianCTPLD - Occupational TherapistCTPLD - Speech and Language TherapistCTPLD - Challenging Behaviour Practitoner
Referrer’s Tel/Contact no:
Referrer’s Address:
Reason for referral – what are the main concerns that have led to the need for a clarification of a possible ASC diagnosis? (Specific details to be included overleaf)

Please state specific concerns/possible indications of ASC:

Development - Was there evidence of any developmental delay, e.g. in acquiring language? Please provide details, if available:
Social functioning – How well is this person able to interact with others, including family, peers, and strangers? Please give details, including any noticeable difficulties in communication.
Restricted interests/leisure activities – Are there concerns that the person has a limited range of interests and activities, in which he or she may invest considerable amounts of time? This may include obsessive behaviours. Please give details.
Activities of daily living – How independently is the person able to live? Does he or she require assistance with daily tasks, such as managing finances, cooking, cleaning, or going out in the community?
Psychological / medical / additional needs – Are there any further concerns about the person’s mental and physical health, including problems with her or his mood? Please give details, including any previous diagnoses:
Other information that may be of significance to the screening and assessment process:
Risk Assessment
Past / Current / Past / Current / Past / Current
Self-harm / Alcohol abuse / Drug Abuse
Suicidal Ideation / Forensic / Violence
Neglect / Aggression

Details about Risk

Please give details on any current or past risks identified above, or any other concerns regarding the person being at risk of harm from others, or of causing harm to himself/herself or others.

Where applicable/available, please include any additional documents pertinent to this referral, including previous psychological or psychiatric reports, or educational statements.

Please also complete and include the Autism Quotient (AQ-10), given on the next page

AQ-10

Autism Spectrum Quotient (AQ)

This form should be completed by the person being referred. Please include this with your referral.

Please tick one option per question only: / Definitely Agree / Slightly Agree / Slightly Disagree / Definitely Disagree
1 / I often notice small sounds when others do not
2 / I usually concentrate more on the whole picture, rather than the small details.
3 / I find it easy to do more than one thing at once.
4 / If there is an interruption, I can switch back to what I was doing very quickly.
5 / I find it easy to ‘read between the lines’ when someone is talking to me.
6 / I know how to tell if someone listening to me is getting bored.
7 / When I’m reading a story I find it difficult to work out the character’s intentions.
8 / I like to collect information about categories of things (e.g. types of car, types of bird, types of train, types of plant etc)
9 / I find it easy to work out what someone is thinking or feeling just by looking at their face.
10 / I find it difficult to work out people’s intentions.