Sheffield Children’s Single Point of Access ADHD and Autism Service Referral - Front Sheet

Please complete this form and attach to a referral letter (see separate guidance), including all relevant information
and details to support the referral in order for it to be triaged into the most appropriate clinic or service.
Incomplete forms will not be accepted.

Section 1 – Key information about the Child/Young Person

Name of child/young person: Click here to enter text. Sex at Birth:
Known as: Click here to enter text. ☐Male ☐Female
Date of Birth: Click here to enter a date. NHS No (if known): Click here to enter text.
Referral for: ☐ADHD ☐AUTISM ☐ADHD & AUTISM ☐Not Sure
Section 2 – Referrer’s Information
Name: Click here to enter text. Address and postcode:
Job title/role: Click here to enter text. Click here to enter text.
Organisation: Click here to enter text.
Contact number: Click here to enter text.
E-mail address: Click here to enter text.
Date of referral: Click here to enter a date.
Section 3 – Further information about the Child/Young Person
Home address and postcode: Name of main carer: Click here to enter text.
Click here to enter text. Relationship to child/young person: Click here to enter
text.
Home telephone: Click here to enter text.
Mobile telephone: Click here to enter text.
Who has parental responsibility for the child/young person? (Please include the relationship to child and address if
different to different to the child/young person’s): Click here to enter text.

School/Nursery Name: Click here to School/Nursery Address: Click here SENCO lead (if known): Click here to
enter text. to enter text. enter text.
Child’s preferred first language: Click Is an interpreter or signer required? If so, please state which: Click here to
here to enter text. Yes ☐ No ☐ Unknown ☐ enter text.
I have explained to the parents/child that information will be collected and Choose an item.
shared to support the assessment process?
Is the child/young person Look After or Adopted? Yes ☐ No ☐ Unknown ☐
Does the child/young person have a Child Protection Plan? Yes ☐ No ☐ Unknown ☐
Does the child/young person have an Education Health and Care (EHC) Plan? Yes ☐ No ☐ Unknown ☐
Does the child/young person have a disability? Yes ☐ No ☐ Unknown ☐
Are there any safeguarding concerns? Yes ☐ No ☐ Unknown ☐
If there is a safeguarding concern, is the child/young person known to social Yes ☐ No ☐ Unknown ☐
care?
Any additional details regarding safeguarding issues: Click here to enter text.

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