Autism Spectrum Disorder (ASD) under 5 years old

Please complete this form if you think that your child may have Autism Spectrum Disorder (ASD). It will take around 20 minutes of your time so please ensure you set aside this time in advance.

On completion, we will assess the likelihood of ASD and book you and your child for a GP consultation. There are two outcomes:

We do not think your child has ASD and we may give other advice.
We think your child is likely to have ASD. We will refer you to the Child and Adolescent Mental Health Service (CAMHS). Unfortunately there is currently a waiting list for this specialty of around 2 years. In the meantime it is recommended you read the
CAMHS Self-Help Information Pack (ASD info is at the bottom of it)

This review works well on mobile but it is easier on a computer.

Tick here if you would like to email yourself this review to complete on computer. (Instant)

Your Email

CHILD’S DETAILS

Patient Name (Child’s)

Date of Birth (Child’s)

Who is the child’s usual GP?

Mobile number to contact you

Your name

Your relationship to the child

If you are not the child’s parent please give a brief description of the reason that they are in your care.

Your Email (If you’d like a copy of the review)

CHILD’S SYMPTOMS

Please now tell us why you think your child has ASD.

Children with ASD have significant and pervasive difficulties in social interaction and understanding, social communication, inflexibility of thinking and repetitive behaviours/interests. Please tell us about these problems below, even if you have to slightly repeat yourself.

Please tell us about any COMMUNICATION or SOCIAL SKILLS problems your child may have in the home or in public.

Please tell us about you child’s INTERACTIONS with other children their age and any problems they have.

Tell us about any UNUSUAL or FIXED INTERESTS or UNUSUAL BEHAVIOURS that your child may have.

Tell us about any DETAILED ROUTINES or difficulties in ADAPTING TO EVERYDAY CHANGE that your child may have.

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data.

Consent

I agree to the privacy policy

CAPTCHA