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Staff Portal

Autism Information and Advice Referral Form

Currently, our system will not allow us to respond to Yahoo email addresses. Please use an alternative email address otherwise we will not be able to follow up on your referral.

Please complete our referral form

Main Contact Details

First Name *

Last Name

Email Address *

Phone *

Street Address *

City *

County *

Postcode *

Which area do you live in? *

Who is your local council? *

What is your relation to the person this referral is about?

What is your relation to the person this referral is about? *

Who is the refferal about?

First Name *

Last Name

Date of Birth *

Do they live at the same address as you? *

Street Address *

City *

County *

Postcode *

If they attend school/college, what is the name of their school/college?

Diagnosis

Does the person have a confirmed diagnosis? *

Which stage of the diagnosis process are they at? *

What diagnosis has the person received? *

Autism Spectrum Disorder (ASD)Attention Deficit Hyperactivity Disorder (ADHD)Pathological Demand Avoidance (PDA)Tourette’s SyndromeAnxietyDepressionOther Mental Health conditionSensory Processing DisorderLearning Difficulties (Dyslexia, Dyspraxia, Dyscalculia etc)Learning DisabilityOther

If other please tell us what diagnosis these are *

Documents

DoumentsPlease include here any documents you think we will find helpful, such as Educational Health and Care plans, Letters of Diagnosis or letters from services etc.

Name of Document

Upload file

No file chosen

Professionals Invovled

Professionals InvovledPlease include any details here of professionals or organisations that are already involved

Name

Orginisation

Email Address

Phone

Reason for Referral *

Consent

Consent *

By completing and submitting this referral form I agree for ASD Helping Hands to hold my details on their records to assist them with managing the support and communication they have with me.

For more information on how we store and use your data please read our Privacy Policy

Address:
ASD Helping Hands, Room 412-416 Breckland Business Centre, Dereham, Norfolk, NR19 1FD
Registered Charity Number: 1175729

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