Autism Referral Application Information Required

Referrers

• Confirmation that you are a Health, Education or Social Care Professional that knows the child well and has observed the child’s presentation.
• Confirmation that you have spoken to the family about our Terms and Conditions (see below).

• Full Name
• Job Title/Role
• Agency/Organisation
• Address
• Contact Number
• Professional Email Address
• Date of Referral
• Length of Time/Involvement with the Child/Family

Child’s Information

• Full Name
• Date of Birth
• Address
• NHS Number (if known)

Parent/Carer Information

• Full Name
• Relationship to Child
• Email Address
• Contact Number

Educational Information 

• Name of Nursery/School
• Address of Nursery/School
• Named Contact at Nursery/School
• Length of Time at Nursery/School

Professional Involvement

• Details of Other Professionals Involved
• Name
• Role (e.g. School Nurse, OT)
• Contact Details
• Length of Involvement with the Family
• Next Appointment Date

Funding Options

• Can the family self-fund?
• Will the family seek financial support from Caudwell Children?

Additional Information

Please provide as much information as possible with specific examples under each heading:

• Previous Autism Assessments (Date, Location, Outcome)
• Reason for Referral
• Social Interactions/Communication
• Behaviour
• Sensory Processing
• Emotional

Terms and Conditions

Referral Form Caudwell Children Autism Service (CCAS). April 2024.

The parents/ guardians of the child I am referring are aware of the following:

• Families will need to attend the CICC in Keele, Staffordshire.
• The family contribution must be paid prior to attendance at Caudwell International Children’s
• Centre (CICC).
• Caudwell Children are unable to provide financial help for travel or accommodation.
• If no contact is made within 6 months then any financial contribution from Caudwell Children may
  be reallocated for use by another child.
• We require a minimum of 48 hours’ notice for cancellation of appointments.
• We will make every attempt to offer you an alternative appointment at a mutually convenient time
  and within a reasonable timeframe. Failure to notify us within this timeframe may incur a charge
  of £75. You may not be offered further appointments until this charge is paid unless there are
  extenuating circumstances.
• Repeat cancellations for funded places may lead to any Caudwell Children funding being
  withdrawn.
• If you decide that you no longer wish to attend Caudwell Children Autism Service, you will need to
  give us 7 weeks’ notice prior to your first appointment in order to qualify for a full refund on your
  family contribution. However, we will take extenuating circumstances into account.

We reserve the right to withdraw services if you fail to abide by the conditions of this agreement as
stated, including:

• Providing false information in relation to your assessment.
• Abuse of the staff team or other families visiting the service.
• Damage to the environment or property of Caudwell Children.

You will be given notice in writing if this occurs and will be liable for the full cost of the service.

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