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Referral Form

Neurodevelopmental Service (NDS) Referral Form

This referral form is for the Neurodevelopmental Service (NDS) only. The NDS is for children and young persons with concerns around Autism Spectrum Disorder (assessment only).

Please note that referrals are for children and young persons up to the age of 18.

It is essential to understand that this is not a diagnosis. However, an Autism assessment will be carried out by a trained professional who is governed by the NMC and adheres to the gold standard set out by the NICE guidelines. Each practitioner is ADOS and ADI-R trained.

This service supports children to recognise certain behaviours set out by the DSM-5 that are concurrent with ASD. From here, a bespoke report will be compiled using qualitative and quantitative data produced in the autism assessment, parental questionnaire, school questionnaire, and the Autism Specturm Rating Scales (ASRS).  Using the information collected, personalised strategies and interventions will be reported. If you wish to seek a full diagnosis, contact your GP with our full report as evidence for a diagnosis in the future.

  • Please complete ALL parts of this form by typing (written/eligible forms may be returned) and include/attach all information and details in support of the referral. This will enable clinical screening and ensure the child’s or young person’s needs will be met.
  • Before submitting this form, you must have agreement from the person who has parental responsibility and (if aged 16 or over) the young person.

Section 1 - Key information about the child/young person (CYP)

Name of CYP
Is CYP a Looked After Child?
Is CYP adopted?
Are there any safeguarding concerns?
Is CYP known to social care?
Does CYP have a Child Protection Plan?
Is there an Early Help assessment and plan in place?
Does CYP have a diagnosed learning disability?
Does the CYP have a physical disability?
Has the CYP undergone Autism and/or ADHD assessment in the past?

Section 2 - Accessible Information Standards

Does the CYP have additional needs related to:

Section 3 - Consent

Young Person (16+) consent

If the young person is unable to consent, then this should be evidenced with the Mental Capacity Act assessment.
I agree that this assessment is an accurate summary of my situation and understand that the information in this assessment will be shared with professionals and services.

Parental Responsibility consent

I/we agree that this assessment is an accurate summary of my/our family situation and understand that the information in this assessment will be shared with professionals and services.
I agree for Wilks Consulting Ltd to contact the child’s school on our behalf.

Section 4 - Referrer’s information

If this referral is from Education, please ensure this is completed by the SENDCo

Section 5 - GP details if not the referrer

Address

Section 6 - Reason(s) for referral

Section 7 – Referral information

Areas to think about: child’s functioning in home/school and with peers. Please provide specific examples.
This might include strategies in school or wellbeing/mental health support.
Please include key areas of concern, e.g. history of difficulties, medical history, allergies, developmental history, family structure, etc.
Areas to think about – family history, circumstance and functioning, family members, family health and wellbeing, housing, employment, money, violence in the household, social integration, and community resources where they live, history of significant events, support networks? Cover strengths as well as risk factors.

Section 8 – Please attach the supporting information to this referral

Neurodevelopmental Service Referral form guidance

Referral guidance:

This is an assessment pathway for children and young persons where there are concerns regarding possible Autism Spectrum Disorder (ASD).

Referrers may wish to enclose additional supporting information, e.g. reports carried out by Educational Psychology, Speech and Language Therapy, Mental Health teams.

Notes for schools and parents:

In situations where a parent/young person requests a referral for assessment, but the school does not share these concerns, a referral may still be considered with supporting information from parent.

Parental responsibility:

In situations where there is shared legal responsibility for a child/young person (e.g. where parents are separated), the parent/carer who has consented to this referral (Section 3) accepts responsibility for informing other parents/carers of this referral and will inform us of any relevant information about shared parental/caring responsibilities and any potential difference of opinion.

Can we help?

If you would like to find out more about our services or training, let us know and we can arrange a free consultation.

Get in touch

Can we help?

If you would like to find out more about our services or training, let us know and we can arrange a free consultation.

Get in touch
Growing Minds
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