Autism Spectrum Condition Screening Form

If you would like to discuss this referral or something other than diagnosis with a member of the Community Adult Asperger Service (CAAS) Team please call 01202 605875 or email dhc.caasenquiries@nhs.net

Please note: We do not accept referrals for ADHD diagnosis

Details of person being referred

Sex assigned at birth *
Gender identifies as *
If English is not the persons first language is an interpreter required? *

If the person has a learning disability please refer to the Learning Disability Service

Referral details

Health/Social Care involvement

Has the client had contact with other Dorset HealthCare Teams or BCP or Dorset Social Services? *

Risk assessment

Are you aware of any hazards to lone visiting *

Details of person making referral

Autism spectrum condition GP screening tool

Must be completed for referrals for diagnosis

Please note - we cannot accept other screening forms the patient has downloaded from the internet (eg AQ10, AQ, etc.)

Please tick either yes or no to indicate whether the following behaviours are interfering significantly in the person's daily life.
Please also provide qualitative detail where possible.

Part A. Social interaction and communication difficulties.

Part B. Restricted, repetitive patterns of behaviour, interests or activities.

Screening forms