Professional

Please use this form to refer a child or young person aged under 18 who needs Autism or ADHD support to the Berkshire West Autism & ADHD Support Service, which is provided by Autism Berkshire on behalf of the NHS Thames Valley Integrated Care Board.

Support for over-18s is available from the Berkshire Adult Autism Support Service, which is also provided by Autism Berkshire on behalf of the NHS.

Professional’s details

First name*

Last name*

Contact Telephone No.*

Email Address (Main)*

Job Title

Referring Organisation

Organisation name*

Postcode*

Parent’s or Carer’s details

First name*

Last name*

Postcode*

Mobile Telephone No.*

Email Address*

Child's details

First name*

Last name*

Address line 1*

Address line 2*

Address line 3*

Town*

Postcode*

Local Authority*

Date of Birth*

Gender*

Ethnic Group*

NHS Number (if known)

GP Practice

Diagnosis*

Berkshire West Autism and ADHD Support Service - I confirm that by ticking the box that the parent has consented to their and their child’s personal information to be shared with Autism Berkshire for the purposes of providing the Autism and ADHD Support Service.*

Brief summary of reasons for referral, if not new diagnosis or recent addition to the waiting list*