Autistic Spectrum Referral Form - St Martin's Hospital

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Complex Health Needs Service
Ash House
St Martin’s Hospital
Clara Cross Lane
Bath
BA2 5RP
Tel: 01225 831566
Fax: 01225 833813
PLEASE RETURN THIS FORM BY POST OR FAX ONLY – DO NOT EMAIL.
AUTISTIC SPECTRUM SERVICE REFERRAL FORM
NAME
DATE OF BIRTH
CAREFIRST ID
ADDRESS
ETHNIC ORIGIN
POSTCODE
TEL NO
GP
CASE MANAGER
TEL NO
TEL NO
PRACTICE
TEAM
N.O.K
CARER’S DETAILS
NAME:
NAME:
CONTACT
CONTACT
DETAILS:
DETAILS:
Has this person been diagnosed with an autistic spectrum condition?
Yes
No
*If yes please provide evidence of the diagnosis (copy of report etc.)
Client’s Preferred Method of Communication
How do you help him/her to understand what is said?
How does he/she tell you what they want to say?
Date: April 2010
Review: April 2012
Author: Yvonne Watts, Administrator/PA
Version: 1.0 (current)
Page 1 of 3
C:\Users\mel.dyson\Desktop\B&NES Docs\Autistic-Spectrum-Referral-Form.doc
Complex Health Needs Service
Ash House
St Martin’s Hospital
Clara Cross Lane
Bath
BA2 5RP
Tel: 01225 831566
Fax: 01225 833813
PLEASE RETURN THIS FORM BY POST OR FAX ONLY – DO NOT EMAIL.
AUTISTIC SPECTRUM SERVICE REFERRAL FORM
NAME
DATE OF BIRTH
CAREFIRST ID
ADDRESS
ETHNIC ORIGIN
POSTCODE
TEL NO
GP
CASE MANAGER
TEL NO
TEL NO
PRACTICE
TEAM
N.O.K
CARER’S DETAILS
NAME:
NAME:
CONTACT
CONTACT
DETAILS:
DETAILS:
Has this person been diagnosed with an autistic spectrum condition?
Yes
No
*If yes please provide evidence of the diagnosis (copy of report etc.)
Client’s Preferred Method of Communication
How do you help him/her to understand what is said?
How does he/she tell you what they want to say?
Date: April 2010
Review: April 2012
Author: Yvonne Watts, Administrator/PA
Version: 1.0 (current)
Page 1 of 3
C:\Users\mel.dyson\Desktop\B&NES Docs\Autistic-Spectrum-Referral-Form.doc
Why are you making this referral?
What would you like from this referral?
Summary of Needs and Risk Factors
Referrer/Organisation:
Tel No:
Referral Date
Client’s Consent to Referral and the potential for the
If NO, why not?
sharing of information within the team
Yes
No
unable to consent
(e.g. lacks capacity)
Medical History:
(Including: primary cause of disability, major illnesses, operations, hospital admissions, emotional distress, psychiatric illness, behavioural distress, epilepsy,
special dietary needs)
Date: April 2010
Review: April 2012
Author: Yvonne Watts, Administrator/PA
Version: 1.0 (current)
Page 2 of 3
C:\Users\mel.dyson\Desktop\B&NES Docs\Autistic-Spectrum-Referral-Form.doc
CURRENT SERVICES RECEIVED (e.g., day placement, education, respite, etc.) PLEASE INCLUDE ALL
CONTACT NAMES AND TELEPHONE NUMBERS.
am
pm
eve
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Complex Health Needs Service Professional Involved (Tick () and name)
Consultant Psychiatrist
Occupational Therapist
Clinical Psychologist
Physiotherapist
Community/Behavioural Nurse
Speech & Language Therapist
Hearing Therapist
Care Manager/Social Worker
FOR OFFICE USE ONLY
Date of Discussion:
Action:
Team Discussion:
Consent and potential for sharing of information discussed with client at initial visit.
Yes
No
REFERRAL ACCEPTED
DATE:
/
/
BY:
Date: April 2010
Review: April 2012
Author: Yvonne Watts, Administrator/PA
Version: 1.0 (current)
Page 3 of 3
C:\Users\mel.dyson\Desktop\B&NES Docs\Autistic-Spectrum-Referral-Form.doc

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