Neurodevelopmental Specialist Service (NeSS)
REFERRAL FORM 
(Revised January 2024)

Please check our referral criteria below to ensure your referral is appropriate for our service as this will avoid unnecessary waiting times for the client. Please see our ‘Referral Criteria and Guidance’ document for further detail.

Acceptance criteria
•	Adults (aged 18+)
•	Nottingham city or Nottinghamshire County resident
•	ASD/ADHD- seeking assessment
•	Short-term and specific post diagnostic support that cannot be sought by another service
•	Adults with an ADHD diagnosis requiring ADHD medication treatment initiation or review 

Exclusion criteria
•	Aged below 18 years
•	Not a Nottingham or Nottinghamshire resident
•	Clients diagnosed/suspected to have Intellectual Disability - refer to Intellectual Disability Service
•	Referrals solely for ongoing mental health support - refer to the Locality Mental Health Team
•	Clients currently experiencing severe mental illness (consultation to professionals may be provided)
•	Support for housing/placements/social care - refer to Adult Social Care
•	No consent from client for the referral 
•	Referral form and questionnaires incomplete/lacking sufficient information

NeSS Section A: To be completed by referrer (pages 1-3)

Client name: 	Date of birth: 	Gender identity/pronouns:	
Full Name 	Date of Birth 	Gender(full) 	
NHS/ Rio No.: 	Email address:	
NHS Number 	Patient E-mail Address 	
Address: 	Contact number: 	
Home Full Address (single line) 	Patient Home Telephone 
Patient Mobile Telephone 	
Person making the referral:	Date of referral:	
Name:     
Position:      
Contact details:      	     	
Client consent: (Tick as appropriate)	
Has the client consented to the referral? 
N.B. We cannot process a referral without the consent of the client	Yes 	No 	
Does the client consent to the service leaving a voicemail?	Yes 	No 	
Does the client consent to contact via email?	Yes 	No 	

GP name and address:	
Usual GP Full Name 
Usual GP Full Address (single line) 

	
Existing neurodevelopmental, psychiatric or physical health diagnoses 
•	Please note any relevant history or formal diagnosis, given by whom, and date of any diagnosis
•	Please provide copies of any diagnostic reports available 
•	Does the person have an Intellectual Disability, or any other registered disabilities? 
NB. If ID identified or suspected, please refer to ID services. 	

     
	
Current medication:	
Medication 

Referral reason: 
(Tick as appropriate)	
Autism diagnostic assessment	ADHD diagnostic assessment	Neurodevelopmental specific support	ADHD medication 	
			
Complete pages 1-3 only

Reason for referral
If referring for diagnostic assessment, please summarise:
•	The main reasons the client feels they may have autism and/or ADHD
•	Any additional issues we may need to take into consideration 
•	Where possible, give your clinical impression regarding possible autism and/or ADHD	
	
If the client already has a diagnosis and is being referred for neurodevelopmental support, please explain what support is being requested.

NB. We do not accept referrals for ongoing support and do not provide support to manage daily living. We also do not accept referrals solely for completing PIP forms. In these cases, please consider a referral for Adult Social Care or local third sector support agencies. Please see ‘Exclusion Criteria’ for further information.	
     	
Has evidence of existing diagnosis of ASD/ADHD* been provided?
*To accept a referral for medication or support, evidence of existing diagnosis will be required. Please provide this with the referral. 	Please tick:	
		
If referring for diagnostic assessment, please ask the person you are referring to complete all relevant ‘Part B: Client Sections’ (green sections) in full, including all questionnaires	

Referrer checklist:	Tick	
Part A: Referrer section completed		
Part B: Relevant client sections completed		
ASRS completed		
AQ-10 completed		
BFIS Quick Screen completed		
Proof of existing diagnosis (if applicable) attached		
Client has consented to the referral		
Please note:Referrals will not be processed unless all relevant sections are completed.

Guidance for referrer: 
Part B of this form is intended for the individual being referred to complete themselves. In some instances, individuals may not be able to complete this independently; in these circumstances, please complete the required sections on their behalf. We are unable to accept referrals for diagnostic assessment without the relevant sections of Part B being completed. 

NeSS Referral Part B: Client section for ADHD assessment
If you are being referred for an ADHD assessment, please fill in all the boxes below AND the questionnaires (pages 7-9)	
Attention and organisation

1.	Tell us about any challenges you have with:
•	concentration, 
•	organising yourself and your things, 
•	starting or finishing tasks, 
•	remembering tasks or activities.

2.	How often is this a difficulty for you, and how does this affect your life?	
Childhood examples (e.g. at school, at home, with friends and family):	
     
	
Adulthood examples (e.g. at work, at home, at university, with friends and family):	
     

	
Overactivity and impulse control

1.	Tell us about times when you have:
•	struggled to stay still when you were supposed to, 
•	acted without thinking of the consequences.

2.	How often is this a difficulty for you, and how does this affect your life?	
Childhood examples (e.g. at school, at home, with friends and family):	
     

	
Adulthood examples (e.g. at work, at home, at university, with friends and family):	
     

	

Please now complete questionnaires on page 8-10

NeSS Referral Part B: Client section for autism assessment
If you are being referred for an autism assessment, please fill in all the boxes below AND the questionnaires (pages 7-9)	
Social communication and interaction 
1.	Tell us about challenges with getting along with people and making friends
2.	Tell us about any challenges in conversation, such as small talk or understanding jokes and sarcasm
3.	Tell us about challenges understanding other people and their behaviour	
Childhood examples (e.g. at school, at home, with friends and family):	
     

	
Recent examples (e.g. at work, at home, at university, with friends and family): 	
     

	
Interests and routines
1.	Tell us about any specific interests you have and how they impact on your life 
(this can be any interest but you may find it difficult to stop doing/talking about it)
2.	Tell us about any set routines that impact on your daily life and how you deal with any changes to these	
Childhood examples (e.g. at school, at home):	
     

	
Recent examples (e.g. at work, at home, at university): 	
     

	
Your senses
1.	Tell us about any sensitivity to noise, smell, taste, textures, light, or other sensory input	
Childhood examples (e.g. at school, at home):	
     

	
Recent examples (e.g. at work, at home, at university):	
     

	

Please now complete questionnaires on pages 8-10

NeSS Referral: Please complete all questionnaires	
Adult Self-Report Scale (ASRS-v1.1) Symptom Checklist	

Please answer the questions below, rating yourself on each of the criteria shown using the scale at the top of the page.  
As you answer each question, place an X in the box that best describes how you have felt and conducted yourself OVER THE PAST 6 MONTHS.  
	
Never	
Rarely	
Sometimes	
Often	
Very Often	

1.	How often do you have trouble wrapping up the final details of a project once the challenging parts have been done?	

	

2.	How often do you have difficulty getting things in order when you have to do a task that requires organisation?	

	

3.	How often do you have problems remembering appointments or obligations?	

	

4.	When you have a task that requires a lot of thought, how often do you avoid or delay getting started?	

	

	

	

	

	

5.	How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?	

	

	

	

6.	How often do you feel overly active and compelled to do things, like you were driven by a motor?	

	

	

	
Never	
Rarely	
Sometimes	
Often	
Very often	

	
AQ-10	
Place an X in the response box for each question.	
Definitely Agree	
Slightly Agree	
Slightly Disagree	
Definitely Disagree	

1.		
I often notice small sounds when others do not.	

	

2.		
I usually concentrate more on the whole picture, rather than the small details.	

	

3.		
I find it easy to do more than one thing at once.	

	

4.		
If there is an interruption, I can switch back to what I was doing very quickly.	

	

5.		
I find it easy to ‘read between the lines’ when someone is talking to me.	

	

6.		
I know how to tell if someone listening to me is getting bored.	

	

7.		
When I’m reading a story I find it difficult to work out the characters’ intentions.	

	

8.		
I like to collect information about categories of things (e.g. types of car, types of bird, types of train, types of plant etc).	

	

9.		
I find it easy to work out what someone is thinking or feeling just by looking at their face.	

	

10.		
I find it difficult to work out people’s intentions.	

	

	

BFIS Quick Screen: Self-Report	
Instructions
How much difficulty do you have functioning effectively in each of these major life activities? 
Please circle the number (or make bold if using electronic version) next to each item that best describes your difficulties in functioning DURING THE PAST 6 MONTHS. If the situation does not apply to you, please circle the 99 in the last column (under ‘does not apply’)
Major Life Activities	
Not at all	
Somewhat	
Mild	
Moderate	
Severe	
Does not apply	

1.	In your home life with your immediate family	
0	
1	
2	
3	
4	
5	
6	
7	
8	
9	
99	

2.	In getting chores completed at home and managing your household	
0	
1	
2	
3	
4	
5	
6	
7	
8	
9	
99	

3.	In your work or occupation	
0	
1	
2	
3	
4	
5	
6	
7	
8	
9	
99	

4.	In your relationships with friends	
0	
1	
2	
3	
4	
5	
6	
7	
8	
9	
99	

5.	In educational activities (college, night classes, occupational training)	
0	
1	
2	
3	
4	
5	
6	
7	
8	
9	
99	

6.	In caring for yourself daily (dressing, bathing and hygiene, eating, sleeping, etc)	
0	
1	
2	
3	
4	
5	
6	
7	
8	
9	
99	

Not at all	
Somewhat	
Mild	
Moderate	
Severe	
Does not apply