Referral Form

Terms & Conditions
- The family contribution must be paid prior to attendance at Caudwell International Children’s Centre (CICC) for workshops and/or assessments.
- All assessments and workshops must be booked and attended within a 12 month period.
- Families will need to attend the CICC in Keele, Staffordshire.
- 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.
Cancellations and Refunds
- Cancellation of appointments and workshop attendance must be given with a minimum of 48 hours’ notice. 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 will incur a charge of £75. You will not be offered further appointments until this charge is paid. However, we will consider waiving this charge where there are extenuating circumstances.
- Repeat cancellations for funded places may lead to any Caudwell Children funding being withdrawn.
- Autism Spectrum Disorder assessments, Occupational Therapy Assessments and workshop packages are bought as a whole and cannot be itemised. Should you be unable to complete the full package, we will not be able to offer a refund on your family contribution; either in full or part.
- 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.
Withdrawal of services
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 be liable for the full cost of the service.
Please note

OT assessments may involve physical activity, e.g. bouncing on a gym ball. bouncing on a trampette, obstacle course, using a swing or vibrating pillows etc.

Please inform us of any health reasons why the child should not participate in the assessment and inform us of any health risks that you feel we should be aware of.
Terms & Conditions*
- The family have been made aware of and accept the above Terms and Conditions.
Are you:*
- Parent/Carer
- Professional making a referral
Please note that referrals will only be accepted from health, education or social care professionals who know the child and family. Applications made by parents/carers will not be accepted.

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Is the child aged 4-11?*
- Yes
- No
We are sorry that at this time you do not fall within Caudwell Children’s criteria.
For further help and advise please visit our charity links section.

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Personal Details of the Child
Please consider the funding process for this referral (tick the relevant box):*
- The family are able to self-fund
- The family will be seeking financial support from Caudwell Children
Child already has a diagnosis of Autistic Spectrum Disorder and has difficulties that might be helped by an Occupational Therapy Assessment*
- Yes
- No
*Due to increasing demand we are currently recruiting additional trained Occupational Therapists to join the charity's dedicated multi-disciplinary team, which will then enable an increase in available appointments. Any referrals received at this time will be held on file and processed as soon as the next appointments become available.*
Child has difficulties which suggest they would benefit from a multi-disciplinary diagnostic assessement for Autistic Spectrum Disorder*
- Yes
- No
Name
First Last
Prefers to be called
Date of Birth*
Age*
Address*
Street Address Address Line 2 City/Town County Post Code
NHS Number (if known)
If not known please leave blank
We are sorry but we cannot accept your referral at this time

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Parent / Carer Details
List*
Name Relationship to child Preferred means of contact (please give email or phone details including any video call access) Has parental responsibility (yes/no)

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Education
Name of Nursery / School*
Address*
Street Address Address Line 2 City/Town County Post Code
Named contact at Nursery / School*
Contact Number*
Length of Time at Nursery / School*
Local Authority (if known)
(e.g. Stoke-on-Trent, Staffordshire, Cheshire East)
Does the child already have;
Please tick the box that relates to your child or leave blank if the answer is no
- Special Educational Needs (SEN)
- Education, Health and Care Plan (EHCP)
- or are currently undergoing assessment for this?
- Any other diagnosis?

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GP Details
GP Name and Practice*
Address*
Street Address Address Line 2 City/Town County Post Code
Phone Number*
Email Address
Is GP aware of referral*
- Yes
- No

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Other Professionals involved /service(s) accessed
(e.g. School Nurse, Speech and Language Therapist (SaLT), Peadiatrician) - to add more entries please click/tap (+)
List*
Name Role e.g. school nurse, OT, etc. Contact details, incl. email Length of involvement Next appointment date What support is this person giving to you and / or your child?

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Reason for Referral
Child has difficulties which suggest they would benefit from a multi-disciplinary diagnostic assessment for Autistic Spectrum Disorder. Reason for Referral What difficulties does the child present with? Please give as much information as possible to support the referral.
Social Interactions/Communication
Behaviour
Sensory Processing
Emotional
Has child had previous ASD Assessment?*
- Yes
- No
If yes please give date:
Child already has a diagnosis of Autistic Spectrum Disorder and has difficulties that may be helped by an Occupational Therapy Assessment.
The child has significant difficulties within their activities of daily living that may be impacted by sensory processing difficulties.
Please give at least 3 examples of how the child experiences the difficulties in the following areas:

Examples:
- Excessive need for movement that is disruptive to a daily routine or activity.
- Poor organisational skills such as getting school bag ready or getting dressed.
- Clumsy, awkward, accident prone, crashing into things.
- Difficulty maintaining their energy level throughout the day
- Over or under reactions to lights, sounds, smells or touch
Self-Care (washing, dressing, eating, sleeping)
Play (games, hobbies, interests)
Learning and Education
Child has had previous OT assessment:*
- Yes
- No
OT assessment may involve physical activity e.g. bouncing on a gym ball or trampette, obstacle course, using a swing or vibrating pillow etc.
Please inform us of any health reasons why your child should not participate in the assessment and inform us of any health risks you feel we should be made aware of.

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Parent / Carer consent to the referral (please tick)
I confirm that this referral has been discussed and the parent / carer (those with parental responsibility) has given informed consent specifically for the following:
- The referral to Caudwell Children Autism Service (CCAS)
- CCAS contacting other services and agencies to gather information about the child being referred
- For the clinical team within CCAS to discuss and share information about the child and /or family, within the team and with Caudwell Children applications team, in order to prepare for their visit.
Please Note:

We cannot process the referral without your consent. Please tick ALL> boxes above and try again.

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Referrer's Details
Name*
First Last
Job Title/Role*
Agency/Organisation*
Address*
Street Address Address Line 2 City/Town County Post Code
Phone*
Email*
Date of referral
Date Format: MM slash DD slash YYYY
Length of time of your involvement with the child/family
If you have any queries about this referral form or would like further information, please contact us prior to sending the referral.

In order to ensure timely response to referral, please ensure that all sections of the referral form are completed prior sending.

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Data Protection GDPR
The General Data Protection Regulations 2018 gives new guidance on how organisations need to to control and process the information that you share with us.

As a Charity providing practical and emotional support to disabled children across the UK, we need to process your data to pursue our legitimate business interests, for example, to provide our services, to safeguard vulnerable children and adults and for administrative purposes.

If your application is successful, the Charity will securely retain and process the information provided in this form, together with any associated information during the time we provide service for you and afterwards until your child reaches age 26 years in line with General Data Protection Regulations 2018 and Caudwell Children Privacy and Information Policy.

If your application is unsuccessful, all documentation relating to your application (both paper and electronic) will be confidentially destroyed after a period of 6 months.

Application Team

Caudwell Children
Caudwell International Children's Centre
Innovation Way
Keele Science & Innovation Park
Newcastle-under-Lyme
Staffordshire
ST5 5NT

Tel: 0345 300 1348
Email: applications@caudwellchildren.com

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CCAS Referrals

Caudwell Children Autism Service – Referral Form

If you are a professional and wish to refer a family for CCAS please fill the form below.

Step 1 of 11

Terms & Conditions

Cancellations and Refunds

Withdrawal of services

Please note

We are sorry that at this time you do not fall within Caudwell Children’s criteria.
For further help and advise please visit our charity links section.

Personal Details of the Child

Parent / Carer Details

Education

GP Details

Other Professionals involved /service(s) accessed

Reason for Referral

Parent / Carer consent to the referral (please tick)

Referrer's Details

Data Protection GDPR

Name	Relationship to child	Preferred means of contact (please give email or phone details including any video call access)	Has parental responsibility (yes/no)

Name	Role e.g. school nurse, OT, etc.	Contact details, incl. email	Length of involvement	Next appointment date	What support is this person giving to you and / or your child?

CCAS Referrals

Caudwell Children Autism Service – Referral Form

If you are a professional and wish to refer a family for CCAS please fill the form below.

Step 1 of 11

Terms & Conditions

Cancellations and Refunds

Withdrawal of services

Please note

We are sorry that at this time you do not fall within Caudwell Children’s criteria.For further help and advise please visit our charity links section.

Personal Details of the Child

Parent / Carer Details

Education

GP Details

Other Professionals involved /service(s) accessed

Reason for Referral

Parent / Carer consent to the referral (please tick)

Referrer's Details

Data Protection GDPR

We are sorry that at this time you do not fall within Caudwell Children’s criteria.
For further help and advise please visit our charity links section.