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REFERRAL TO THE ASD SERVICE (CHILDREN)

Following your contact with the practice, please complete the following steps. This is required for all child Autism Spectrum Disorder (ASD) service referrals.

Submit our web form below.
Download the appropriate school questionnaire below based on your child's age and completed this with the school. Return a completed copy it to the practice via bnssg.thefamilypractice@nhs.net
- Social Communication Questionnaire Setting (primary school aged children)
- Social Communication Questionnaire Setting (secondary school aged children)
Our referral team will process your referral request once we have received both of these forms.

Please note: This form is only for patients registered at this practice. If you have not previously discussed this referral with your GP we may reject your referral request.

Patient Details

Main Problems

Communication

Behaviour

Other Children

Emotions

Sleep

Exercise

Eating Habits

Sensory Issues

Childhood Experiences

AQ-10 Questionnaire

The AQ-10 helps indicate whether someone should be referred for an autism assessment. This is for parents or carers to complete about a child aged with suspected autism who does not have a learning disability.

Which version of this form you must complete is dependant on the age of the child.

Please indicate your child's age group: *

1. S/he often notices small sounds when others do not: *

2. S/he usually concentrates more on the whole picture, rather than the small details : *

3. In a social group, s/he can easily keep track of several different people’s conversations : *

4. S/he finds it easy to go back and forth between different activities : *

5. S/he doesn’t know how to keep a conversation going with his/her peers : *

6. S/he is good at social chit-chat : *

7. When s/he is read a story, s/he finds it difficult to work out the character’s intentions or feelings : *

8. When s/he was in preschool, s/he used to enjoy playing games involving pretending with other children : *

9. S/he finds it easy to work out what someone is thinking or feeling just by looking at their face : *

10. S/he finds it hard to make new friends : *

1. S/he notices patterns in things all the time : *

2. S/he usually concentrates more on the whole picture, rather than the small details : *

3. In a social group, s/he can easily keep track of several different people’s conversations : *

4. If there is an interruption, s/he can switch back to what s/he was doing very quickly : *

5. S/he frequently finds that s/he doesn’t know how to keep a conversation going : *

6. S/he is good at social chit-chat : *

7. When s/he was younger, s/he used to enjoy playing games involving pretending with other children : *

8. S/he finds it difficult to imagine what it would be like to be someone else : *

9. S/he finds social situations easy : *

10. S/he finds it hard to make new friends : *

Select a Service

Please indicate below which provider you would like to be referred to.

For more information on available autism providers (CYP column) and right to choose, please read this page.

Please be aware, you may be asked to choose an alternative service if your chosen provider does not engage with our local referral processes. We will contact you if this is necessary.

Resources

Resources are available for parents of children with neurodivergence and can help even while awaiting assessment.

Please look here for further support: https://sirona-cic.org.uk/children-services/resources/advice-and-signposting-2/

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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REFERRAL TO THE ASD SERVICE (CHILDREN)

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