Understanding My Autism Referral Form

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Thank you for your interest in the Understanding My Autism pilot project. Please complete all details below.

If you are a professional and are referring a child or young person to the course, please complete your details at the end of the form.

The deadline for applications is Friday 17th May.

I would like to apply for my child/young person to attend *

Name of parent/carer(s) *

Name of child/young person *

Email address of parent *

Contact number of parent *

Home address *

Home address of child/young person if different to parent/carer

In which district of Hertfordshire does the child/young person live? *

School year *

Year 3

Year 4

Year 5

Year 6

Year 7

Year 8

Other:

Age of child *

Gender *

Ethnicity *

School setting *

Mainstream primary school

Mainstream secondary school

Independent school

Specialist school

Home educated

Attending an Educational Support Centre (ESC)

Other:

Is the child/young person entitled to free school meals? *

Yes

Does the child/young person have a diagnosis of *

Autism

ADHD

Both

Neither

Is the young person on a waiting list for a diagnosis of *

Autism

ADHD

Both

Not applicable

When was the child or young person diagnosed? *

Less than a year

1-2 years

3-5 years

Over 5 years

Not applicable

Does the child or young person know about their diagnosis, or if they are not yet diagnosed, that they are on the waiting list for a diagnosis? *

Yes

Not sure

Does your child have any co-occurring or additional needs? *

Does your child require any reasonable adjustments? *

Does your child have an EHCP? *

Yes

Awaiting EHCNA

Other:

Is the child or young person under the following plans? *

Families First Assessment

Child in Need

Child Protection

None of the above

Is the child or young person receiving support from CAMHS/PALMS or similar service? If yes, please give brief details *

If you are applying for the face to face course, please give details of any allergies

I consent to my child taking part in this course *

Yes

I consent to taking part in this course (child) *

Yes

Why would you like to attend this course? (child's view) *

Name of referrer (if applicable)

Job title of referrer (if applicable)

Email of address of referrer (if applicable)

Contact number of referrer (if applicable)

For referrers: please outline any safeguarding issues , or concerns there may be around the CYP or parent attending a session

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