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Assessment for Asperger Syndrome

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Assessment for Asperger Syndrome - Practitioner Referral Form

Below is a brief questionnaire for autism and Asperger Syndrome. This is not a diagnostic tool. This measure serves as a screen for the presence of symptoms related to Asperger Syndrome and provides guidance for referring people to the Adult Asperger Service.

Please Note:  We are not able to accept referrals for individuals who are currently open to secondary care services such as Community Mental Health Teams. Individuals who are open to such a service should not be discharged specifically to obtain an assessment with Outlook South West’s Asperger Syndrome Assessment Service if they have ongoing mental health needs. Instead, they should remain within that team and seek such an assessment as part of their ongoing care package.

Please read the following statements carefully, and rate how strongly you agree or disagree with each one.

Please provide further details and examples of the difficulties the patient is experiencing below. The completed referral can then be sent to the Outlook South West Adult Asperger Assessment clinic for further diagnostic assessment. 

(e.g parent/spouse/partner)

Please note: An acknowledgement of the receipt of this referral will be copied to the patient’s GP. It is a requirement of our service to keep GPs informed whilst their patients are involved with our service.

Using the subheadings below, please could you provide a short description of the difficulties that the patient is experiencing that have led you to request an assessment for Asperger Syndrome.