BASIS Initial Enquiry/Referral Form
Please complete this section with details about the person wanting to access support.
Name of the person who will be submitting this form to BASIS:
Title:
Gender:
Male
First Name: *
Female
Other
Prefer not to say
How do you like to be known?
(if different from first name)
Last Name:*
Date of Birth:*
Address: *
Post Code: *
Phone Number:*
Mobile:
Landline:
Email Address:*
Contact Preference:
(Tick more than one
if applicable)
Email
Phone
Someone you know (please give details below)
If you would like to receive information but do not have access to email, or would like
somebody else who does have an email address to receive the information as well as you,
please provide their details below.
First Name:
Last Name:
Relationship to
You/Role:
Phone Number:*
Organisation:
Mobile:
Landline:
Email Address:
What is your ASD
diagnosis? *
Date/age of
Diagnosis:
If other, please give details
Autism
Asperger’s
Syndrome
ASD
Practitioner/Clinic
Name: (if known)
Seeking
Diagnosis
Other
Please tick to show what sort of support you would like to discuss with us (you can tick more than one):
Learning about autism
Finding social opportunities
Mental Health
Self esteem and confidence
Getting a diagnosis
Finding learning opportunities
Finding a job
Help in a job I already have
Explaining autism to someone I know (friend, family or professional)
Other
Finding new hobbies or interests
Please give details
Is there any background information you would like us to know?
For example: How do you spend your time? Are you part of any activity groups? Who do you live with?
Equality Information
Please note: The questions below are for statistical purposes. This information helps us ensure the service is
available to all who would like to access it. If you choose not to answer, it will not affect your participation.
What is your ethnicity?
White
Mixed
Asian/Asian British
Black/Black British
Chinese
Other (please state)
What is your employment/income status? (tick more than one if applicable)
Employed 16+ hrs per week
Employed under 16 hrs per week
Receiving Employment Support Allowance
Receiving Disability Living Allowance
Volunteering
Receiving Job Seekers’ Allowance
Attending a work related programme
Receiving Personal Independence Payments
The information that I have provided is correct to the best of my knowledge.
I understand that this information will be used to assess potential risks while I access the service.
I understand that my details will be treated in accordance with the confidentiality policies of Autism West
Midlands. If you would like to view these policies please ask a member of the Aspire team.
Signed: *
(by the person accessing support)
Print Name: *
Date:
Please print and post to: Aspire, Autism West Midlands, Regent Court, George Road, Birmingham, B15 1NU
or email as a Word Document to [email protected].