Please use this form to refer a child or young person under 25 who has a need of Autism or ADHD support to the Berkshire West Autism and ADHD Support Service, provided by Autism Berkshire on behalf of Berkshire West NHS CCG.

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*