1. What sort of services are required?

Please describe the assistance required.  Please note we will reject requests for personal care support, providing a care package, key worker support or employment/volunteering support.

Please be aware that we encourage parents / carers to attend our drop-in to find out more about the services on offer at CAAS.  If one of our support workers believes the person being referred is a candidate for bespoke family support, they will let them know how to access it and add them to our waiting list.  Please therefore only choose ‘families – bespoke family support’ from the list below if you have been asked to do so by a member of our team.

Please do let us know if you need any support to access our drop-in by contacting us on 020 8429 1552 or by emailing enquiries@adhdandautism.org*

2. Please tell us a little more about the nature of the services / support that is required*

3. Please type your initials into this box for our database records.*

4. If you are a professional referring someone for support, which of these categories best reflects you/your organisation/your work? 
If you have referred yourself please choose which of these categories best reflects how you heard about CAAS*

5. Do you have, or are you seeking support for, a family that cares for an ADHD/Autistic child aged under 11yrs?*

6. Do you have, or are you seeking support for, a family that cares for an ADHD/Autistic young person aged 11-18yrs. Please choose 'yes' here if your child is accessing SIBs or Creative Group. *

P1. What is your Full Name?*

P2. What is your Job Title?*

P3. What organisation do you work for / represent (please give it’s name)*

P4. What is your phone number? (please provide the number we can most easily access you on, to discuss the referral)*

P5. What is your email?*

P6. Do you know of any other organisations involved with this person/family that is being referred?

P7. Please share any risks in respect of this referral that need to be recorded or discussed

Consent


Has the person being referred consented to this referral, and understands that this means they consent for us to hold their data and are happy for us to contact them to arrange support*

P8. Referrer has consent to store information and contact to arrange support services*

P9. Referral consent date

Y1. What is their First or Given Name?*

Y2. What is their Surname, or their Last or Family Name?*

Y3. Please type your initials into this box for our database records*

Y4. What is their preferred name / what name do they wish to be known by?

Y5. What is their home address?

Y6. What is their postcode?*

Y7. What Borough do they live in?*

Y8. What School do they attend?

Y9. What is the email of their parent carer (we will not email the young person directly to arrange support initially)

Y10. What is the young person's date of birth?*

Y11. What is their gender?*

Y12. What is their ethnicity?*

Y13. What is their sexuality?*

Y14. What is their religion / faith group?*

Y15. Please fill in their user group for our database record (please choose option “ADHD/Autistic Child/Young Person")*

Y16. Please tell us about the young person's  conditions/status:

Condition 1*

Condition 2

Condition 3

Condition 4

Condition 5

Condition 6

Y17. GP Details:
Please provide their GP details including GP Name, Address, Phone number.  Please include postcode

Y18. Please provide details of who should be contacted in an emergency during any support work with that young person.  Tell us the emergency contact’s name, relationship to the young person, phone number and email address

Y19. Is the young person able to independently engage with our services, in person, by phone, email or video?*

Y20. Please tell us about any accessibility or engagement needs the young person has (eg will need large text documents, hearing loop etc)

Y21. Does the young person have a learning or intellectual disability?

Y22. Consent: Usage of the young person's data. I give consent for CAAS to process and use the personal information of this young person, solely for the purposes of enabling them access to CAAS services. I understand that all personal information will be kept confidential. Some details will be anonymised and used for monitoring for funders.

If you have consent, please choose "Yes - Referrer has consent"

Y23. Please fill in your full name in this box to confirm consent, and state your relationship to the young person (parent, teacher, dr, etc.)

Y24. Date of consent (Enter today's date to confirm consent)

F1. What is the name of the relevant child?*

F2. What is the condition(s) of relevant child, eg Autism, ADHD.  It is helpful to tell us if the condition has been diagnosed, is suspected, or if the child is on a waiting list for diagnosis*

F3. What school does the relevant child attend?*

F4. What is the Date of Birth of the relevant child?*

F5. How many children (under the age of 18) are there in the household in total?*

A1. What is their First or Given Name?*

A2. What is their Surname, or their Last or Family Name?*

A3. What is their preferred name / what name do they wish to be known by?

A4. What is their home address?

A5. What is their postcode?*

A6. What Borough do they live in?*

A7. What is their email?

A8. What is their telephone number?

A9. Please tell us how they would prefer to be contacted by us (eg by phone, or by email) and if they have any communication needs that we should be aware of

A10. What is their date of birth? (if you do not know the adult’s date of birth, please use 01/01/0001)*

A11. What is their gender?*

A12. What is their ethnicity?*

A13. What is their sexuality?*

A14. What is their religion / faith group?*

A15. Please tell us about the adult's condition/status. If you are the parent/carer of an ADHD/Autistic individual please choose that in one of the 'condition' boxes as well as tell us about any conditions of your own. 

Condition 1*

Condition 2

Condition 3

Condition 4

Condition 5

Condition 6

A16. Please provide their GP details including GP Name, Address, Phone number.  Please include postcode

A17. Please provide details of who should be contacted in an emergency. 
Tell us the emergency contact’s name, relationship to the adult, phone number and email address

A18. Are they able to independently engage with our services, in person, by phone, email or video?

A19. Please tell us about any accessibility or engagement needs the adult has (eg will need large text documents, hearing loop etc)

A20. Do they have a learning or intellectual disability?

A21. For our database record, please can you select from the below list which best represents the person whose details you have just provided.  Please choose either Carer of ADHD/Autistic Adult, Carer of ADHD/Autistic Child/Young person, or ADHD/Autistic Adult*

A22. Is there anything else you would like us to know that hasn’t been covered elsewhere in this form?

A23. If you have given consent, please choose Yes - Webform*

A24. Please type your initals in this box to confirm consent

A25. Date of consent (Enter today's date to confirm consent)

Consent: Newsletters and Information emails

I give consent for CAAS staff to contact me to share information about the range of services that CAAS provides in NW London, the ways in which I might be able to support CAAS, and to provide information from other organisations that might be helpful to me through a newsletter or emails related to CAAS activity.  I understand my contact details will not be shared with any other organisations. 

A25. If you consent, please choose option Yes - Webform*

A26. If you have given consent please type your initials to confirm

Consent: Sharing information. Individual and group sessions at CAAS.

I give consent for CAAS staff to share information about me (and any of my children being supported by CAAS) with other agencies on a need-to-know basis.  This may be for example if we attend a meeting with you, or so we can assess how we can work with other agencies that may also be supporting you.  I understand that if I do not consent it may affect the depth of support CAAS can provide.  We will not share personal details with any third-party agency, unless we need to do so to meet our legal duties around duty of care.

A27. If you consent, please choose option  Yes - Webform*

A28. If you have given consent please type your initals to confirm

Consent: Images and Videos 

I give consent for photographs / videos of me to be shared on CAAS website, social media, funding applications, monitoring reports or publicity materials to help achieve CAAS aims.

A29. If you consent, please choose option Yes - Webform*

A30. If you have given consent please type your initals to confirm