OAADS Referral Form - OAADS REFERRAL FORM

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Please try to complete all sections and discuss with us if you have problems with this.

Email: referral@kingwood.org.uk or leave a message on 01235 359388; we will respond within five working days of your contact.

NB The ‘supporter’ is the person requesting assessment on your behalf (if applicable).

By submitting this form you are agreeing to your details being held on a confidential database.

In order for us to process your referral:

1.We will need to share relevant confidential information with the clinic.

2.We may also need to contact & share information with those who may be involved in your care & well-being.

3.By signing this form you or your supporter are agreeing to the above. All personal information will be treated as confidential and subject to the Data Protection Act 1998, by all services. You may request access to the personal information held about you.

About you

*First Name

*Surname

NHS Number if known

*Date of birth

*Address

*Postcode

*Phone number

Email address

(By letting us know your Email Address you are giving us consent to email you)

*Next of kin

Your ethnic origin

*First language

Your religion/belief

*Your gender

Male

Female

Gender Fluid

Transgender

Gender other

Other

If you have selected 'other'. Please let us know here what gender title you prefer

*Name of your GP: Dr

*Phone number

*Practice address

*Postode

About your supporter (if applicable)

Is someone requesting an assessment on your behalf?

Yes

Your social situation

*Who do you live with? (select all that apply)

Alone

With Family

With Spouse

With parents

Paid carers

Residential care?

Comments

*Are you currently employed?

Yes

About your referral

*What is your reason for requesting an Autistic Spectrum assessment?

*What do you hope will be different by having an referral and diagnosis?

Any particular concerns or additional information

*Do you have any particular sensory issues or other difficulties which we should take into account where possible when arranging the assessment interview? (ie difficulties with particular environments)

Yes

If 'yes' please give details here if possible.

Professionals currently or recently involved with you and/or family/carers

*Name

*Phone number

*Profession/relationship

*Add another professional?

Yes

*Relevant medical history. Including current medication, possible related diagnoses and/or Mental Health Team involvement, current or past (if none please indicate that below also)

Thank you for taking the time to complete this form.

*Please complete the following box - this will act as your electronic signature

*Date of signature

Your supporter/referrer's should fill in this section.
Please complete the following box - this will act as your electronic signature.

Name

Job Role

Date of signature

If you are a Supporter/Referrer, please indicate if you have helped the client complete this form

I have helped the client complete the form

The client completed the form without my assistance

*Do you want somebody to receive copies of correspondence to you from Autism at Kingwood and the Diagnostic Clinic, including (where agreed) email correspondence?

Yes

*Your name (this will act as your electronic signature)

*Date

Consent to correspond by email

*Autism at Kingwood has a duty to manage and handle the information we hold about you in accordance with the Data Protection Act 1998 and the General Data Protection Regulation 2018.

Autism at Kingwood is registered with the Information Commissioner's Office under Data Protection number Z1003590.

We will not contact you via email, unless you have already contacted us this way or requested that we do so, by providing us with your email address & giving your consent below. Please only contact us by email so we can ensure communication is as effective and confidential as possible.

Technology is not perfect, so as with letters we cannot guarantee every email you may send to us is received. The reasons a message may not be received can be numerous and the problem may well be nothing to do with us. If you email us and do not receive a response, please contact us by another method, such as phone: 01235 359388.

For reasons of confidentiality we prefer to receive the information form by mail. If you do wish to send the information form to us by email, we recommend that you password protect the form, and let us know the password either by phoning us or by sending it by mail.

I consent to communicating by email with Autism at Kingwood (please complete the consent section below)

I do not wish to communicate by email with Autism at Kingwood

*I have read and I understand the information above and am happy to be contacted by email, either in response to email from me, or at my specific request.

Where I have provided details of a person I would like to be included in Autism at Kingwood’s further correspondence with me, I am happy for Autism at Kingwood to contact them by email.

I accept that confidentiality of email cannot be guaranteed and that Autism at Kingwood is not liable for the confidentiality or security of any message once it has been sent to me.

I understand that I can change my mind and it is my responsibility to withdraw this consent and inform Autism at Kingwood immediately.

I understand it is my responsibility to inform Autism at Kingwood of any change to my email address in writing or face to face contact. An email from my new address will not be taken as informing of change.

Insert email address below

*Your name (this will act as your electronic signature)

*Date

*OCCG (Oxfordshire Clinical Commissioning Group) has commissioned a new autism diagnostic assessment process which gives you a choice between two options. Both services offer a similar standard and quality of assessment.

Option 1

Healios provides a comprehensive online diagnostic assessment service which can be accessed in your own home – all you need is access to the internet and a private computer, tablet or smart phone. Healios can offer an autism diagnostic assessment appointment more quickly because they have more clinicians available. For further information about the service, please read the information sheet on the Autism Oxford website, or contact Healios on: Telephone: 0330 124 4222 or E-mail: info@healios.org.uk

Option 2

OCCG has also commissioned Autism at Kingwood to provide the Oxfordshire Adult Autism Diagnostic Service (OAADS) which will carry out face-to-face diagnostic assessments locally in Oxfordshire. This currently takes place in Didcot but hopes to expand to Witney, Oxford and another location in North Oxfordshire once established. For more information, please read the information on the Autism at Kingwood website, or contact Autism at Kingwood on 01235359388.

Please tick the box of the service to which you would like to be referred, then insert your name and date below:

Healios online assessment

OAADS face-to-face assessment

As you have selected an OAADSS face-to-face assessment please state your location preference, although we may not be able to meet this as yet)

Preferred Location 1

Preferred Location 2

*Your name (this will act as your electronic signature)

*Date

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