Autism Spectrum Disorder (ASD) Child over 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)

The Form. Made up of THREE sections:

The Child’s Details
School Report / Assessment*
The Child’s Symptoms

*School reports are very helpful in the assessment and referrals benefit from having these included. Please have these to hand to upload into this form or hand them into the practice afterwards for us to copy and upload.

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

CAMHS will only accept referrals for children who have already had their problems discussed and assessed at school and had any available input from Speech and Language Therapists or Educational Psychologists.

My child’s problems have been discussed at school and I have been advised to seek referral by their GP

CAMHS does not consider ASD referrals for children who use alcohol or drugs.

I confirm there is no alcohol or drug use

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.

School that the child attends

School Year

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

SCHOOL REPORT / ASSESSMENT

Please upload any school reports or assessments that have been done and you feel would be useful to CAMHS.

File Upload

Maximum file size: 52.43MB

YOUR CHILD’S SYMPTOMS

Children with ASD have significant and pervasive difficulties in social interaction and understanding, social communication, inflexibility of thinking and repetitive behaviours/interests.

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

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

Please tell us about you child’s RELATIONSHIPS with their classmates and friends and any problems they have.

Tell us about any UNUSUAL or FIXED INTERESTS or UNUSUAL BEHAVIOURS that your child may have and how these effect your child’s functioning.

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