Autism Support Plus

This web form is for partner organisations who have a contract with the National Autistic Society to provide support to their members/clients.

The National Autistic Society Autism Support Plus team will contact the person you refer to us within 2 working days to arrange an initial advisory call at a mutually convenient time. If you have any questions, please email us at AutismSupportPlus@nas.org.uk.

Please answer the following questions, questions marked with an asterisk require a response.

Referring organisation details

Name of referring organisation

Caseworker name

Caseworker email

Caseworker Telephone Number

Caseworker mobile number

Client details

Reference number (if relevant):

If the person requires anonymity, please provide details here:

First name

Last name

Email

Address line 1

Address line 2

Address line 3

Address line 4

Postcode

Town/city

Telephone number

Mobile number

Does the client require communication adjustments? Yes No

(i.e. They prefer for NAS to phone them to arrange the advisory call or they prefer all communication to take place by email or SMS)

Can we leave a voicemail on the client’s answerphone? Yes No

Has the client given permission to have these details shared with the National Autistic Society Benevolent Fund Service? Yes No

Details of the person the referral is about (either child or self referral)

Name

Age

Date of birth

Any other ethnic group, please describe

Has the person received a diagnosis of autism or have they been advised by a professional to have an assessment?

If the person has any other medical conditions, please enter them here

Are any medical/professional agencies involved with person? Please enter details here

Summary of situation (information about the person, areas of concern, support required, what has been happening etc.).

Please list any supporting documents you have available such as an education plan or diagnostic assessment report here.

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Autism Support Plus

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