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* 1. Name of child/young person:

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* 2. Date of birth:

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* 3. Names of parents/carer:

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* 4. Contact details (Please include home address, email address and a telephone number):

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* 5. Name of school/setting child attends, if any:

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* 6. Please give a brief description of identified concerns:

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* 7. Any other support received / professionals involved with your child and their role:

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* 8. Does the child have/awaiting a formal diagnosis of ASD?

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* 9. Name/relationship to child/contact details of person making request for support (Please obtain permission from parent/carer before making this referral):

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