Autism Referral Questionnaire

INSTRUCTIONS

·         Please complete the “About You” section

·         Please complete the Autism Questionnaire AQ-50 (Autism Screening Sections 1-5)    

·         Please complete the ProblemShared Suitability Criteria Declaration (only if you want to be referred to this service)

If you don't have access online, or you struggle to complete any of the above, then please talk to the Reception Team who can arrange an appointment with a clinician for you to discuss your symptoms. Please note, there may be a wait for an appointment.

1. Fill out the form below

2. Input your questions on the computer at : https://psychology-tools.com/test/autism-spectrum-quotient  or by clicking link

3. Score your form online and inform us by answering question 51.

N.B. if you have a printer you can do it all on the website then print your completed form with your score and hand this to reception

Follow this link to get your score https://psychology-tools.com/test/autism-spectrum-quotient

If no service is selected you will be referred to the local service which has a 5+ year wait.   If you have selected ProblemShared please ensure you complete the exclusion criteria. If you have not answered this we will not be able to refer you.

You are not suitable for an online assessment with ProblemShared at this time if any of the following statements apply to you:

If you meet the eligibility criteria, we will refer you onto your chosen service. You will be notified via SMS message to let you know that we have sent the referral, or if you don't meet the criteria.