Autism Service - Bucks Self-Referral Form

Your Name :
Your Address :
Telephone Number: / Email Address:
Date of birth: / Date you are sending this Referral:
Do you speak English? Yes / No / If you don't speak English:
Which language do you speak?
Do you know someone who can translate for you? Yes / No
Name of translator :
Telephone Number:
(if you don't know anyone who can translate for you we will try to find someone)
Do you have any special requirements we would need to be aware of for when we meet you? / Please give details:
Do you have a diagnosis of Autism/Asperger’s? Yes/No
Do you have a Learning Disability/Difficulty? Yes/No
How did you hear about Connection Support Autism Service?
Is anyone helping you to complete this form? Yes/No
Their Name: / Their Telephone Number:
Their organisation Name (if any) :
Relationship to You :

Please make sure that you complete each section so that we can understand your situation. If this form is not fully completed it may be returned to you.

If you need help to complete this form please call us on 01296 484322.

If a section does not apply, please write N/A in the space provided.

Details of where to send your completed Referral can be found on the last page of this document.

Who helps to support you at the moment?

Support Network Members / Names / Contact Details
(Phone Numbers etc.) / Can we contact them for further information?
Yes / No
Close Family Members
Carers
Doctor
Psychiatrist
Connexions Worker
CPN – Community Psychiatric Nurse
Social Worker
Other Support (please tell us who -including close friends)

Do you have any physical health problems, mental health issues or long term disabilities? Yes / No

If you would like to give us more information about your health, please write here:

We will need to talk to you on the phone before we visit you.

When is the best time to contact you on the phone? ______

If we cannot get hold of you on the phone number you have given, is there someone else we can talk to who can get a message to you?

Name of Contact: ______

Their phone number: ______

Tell us about your Housing Support Needs
Tell us about where you are living now / Do you live with family/friends? Y/N
Do you live on your own? Y/N
Do you live in supported accommodation? Y/N
Will you need help with any of the following things: put a tick (√ ) n the box
Support in building basic life skills such as:
cooking, using public transport, opening a bank account, filling in forms etc.
Meeting new people/making new friends
Making and keeping appointments i.e. doctors, dentist, bank
Accessing training, education or work (paid or unpaid)
Improving your health and general wellbeing
Debts/budgeting/bills
Finding suitable accommodation
First tenancy or keeping your tenancy
Being new to the area
Other (please give details)

Please provide some information as to why and how you need support:

Continue on a separate sheet if necessary
Your Personal History
We need to know if it’s OK for support workers to visit you at home, so please tell us the following information.
Do you have any history of the following?
Yes / No / Yes / No
Aggression from you – towards other people either verbal or physical / Self Harm
Arson- by you / Sex Offences by you
Domestic Abuse – either by you or to you / Do you have pets living in the home?
What sort of pets?
Substance / Alcohol use / Other (please specify)

Are there any reasons why it may not be safe to visit you at home?

Yes/ No /Sometimes

If Yes or Sometimes: please give more details about why or when it might not be safe to visit you, plus any triggers that we may need to be aware of.

Are there any other safety issues that you want to warn us about?

We will contact you if we intend to visit you. If it's unsafe to visit you at home, we will arrange to meet you somewhere else.

Who else is living at your address and what relationship are they to you?

Name / Relationship to you?
e.g. Mother, father, etc.

Monitoring our Service

We want to provide a service, which is fair and available to everyone. To help us monitor this, please answer the following questions:

Gender: Male ☐ Female ☐ Transgender ☐

Do you consider yourself to have a disability? Yes ☐ No ☐

Your Ethnic Origin: (Tick)

A – White / British
Irish
Gypsy, Romany, Irish Traveller
Other
B – Mixed / White & Black Caribbean
White & Black African
White & Asian
Other
C – Asian or Asian British / Indian
Pakistani
Bangladeshi
Chinese
Other
D – Black or Black British / Caribbean
African
Other
E- Other Ethnic group / Arab
Other
F - Refused / Refused / Not Given

Thank you for taking the time to complete this form. Please return it by post to:

Connection Support
Claydon House
1 Edison Road
Rabans Lane
Aylesbury
Bucks, HP19 8TE
Tel:01296 484322

Or, you can return it by:

Scan / email to:

Please type: 'Referral' on the Subject Line

What happens when we get your referral?

  • When we receive the form it will be given to our allocations team for a decision to be made on how we can help you. We will normally contact you within a few days.
  • We may need to phone you, visit you or arrange an appointment at one of our Access Points in order to get more detailed information on how we can help you.
  • If we need to meet you we will ring you to make an appointment, so please make sure that you have given us the telephone numbers where we can contact you.
  • If we cannot contact you by phone, we will send you a letter offering an appointment. We will ask you to ring us to confirm the appointment. If you don't confirm the appointment, your appointment may be cancelled.
  • If we are not the best people to help you we will tell you if there is somewhere else where you can go for further help.
  • If you want to know the progress of your referral, please ring 01296 484322. The office is normally open between 9.00 - 5.00 pm Monday to Friday.

Keep this page so that you have the phone number for the office if you need to contact us.

Connection Support Autism Self Referral July 2105 1