Diagnostic referral form

Children
Autism SA accepts referrals from parents and professionals for children that they suspect may have an Autism Spectrum Disorder.

Adults
Referrals are also accepted from adults who wish to refer themselves for an assessment.

If you prefer you can also download the referral form to complete offline and return to Autism SA, details included in the form.

Download referral form

Please note that due to current funding arrangements Autism SA’s diagnostic service is not able to accept referrals from, or conduct assessments with, individuals from interstate or overseas. We can only accept referrals from individuals residing in South Australia.

All referrals must be in writing. If you are unable to complete the below referral form in one sitting you can scroll to the end of the form and click on the “Save and Continue Later” option, you will then be given a link so that you can access your referral for up to 30 days to complete it.

Person being referred
Surname*
Given Name/s*
Gender
- Male
- Female
Date of birth*

Day
Month
Year
Age at referral
Please enter a number from 0 to 100.
Address*
Please note that due to current funding arrangements Autism SA’s diagnostic service is not able to accept referrals from, or conduct assessments with, individuals from interstate or overseas. We can only accept referrals from individuals residing in South Australia.

Street Address Suburb State Postal Code
Postal address
If different to residential address

Street Address Suburb State Postal Code
Telephone (Home)*
Telephone (Work)
Mobile
Email address*
Preferred method of contact?*
Day Activity
E.g. employment, university, school or child care centre (whichever is applicable)
Guardian (If appropriate)
Guardian Status
- Parent/Carer
- Legal Guardian
Mother Name
Father Name
Legal Guardian Name
Address
Street Address Suburb State Postal Code
Telephone (Home)
Telephone (Work)
Mobile
Email
Referring Person Details
Name and Surname*
Relationship to person being referred*

E.g. Self referral (for adults), parent, grandparent, other relative, GP
Agency
Email*
Address*
Street Address Suburb State Postal Code
Telephone*
Signature of person completing this form*
Outline examples of behaviour and responses that are causing concern in the following areas.
Socialisation
(e.g. response to family, peers, significant others, ability or interest in making friends, empathy, understanding of emotions in self and others)
Communication (Verbal and Non Verbal)
(e.g. use of gesture, facial expressions and eye contact; development of language, abnormality in content of language; imaginative ability)
Restricted Range of Interests/Resistance To Change
(e.g. play activities/interests; issues with change; development of routines; preoccupations with objects, activities or behaviours; unusual motor movements, over or under reactions to sensory input)
Additional Information
Activities that the person is resistant to:
Activities that the person really enjoys:
FIle Uploads
Please include copies of assessments: i.e. Speech Pathology; Occupational Therapy; Psychology.
Drop files here or

Max. file size: 25 MB.

Save and Continue Later

What is autism?

Autism Signs

Getting a diagnosis

Supports & services

Are you new to autism & NDIS? We can help.

Family supports

We can also provide support for families

Other supports

Early Years

School Years

School Leavers & Adults

Parents & Professionals

Early years

School years

School Leavers & Adults

Training & Consultancy

Requests for training

Research

What is autism?

Autism Signs

Getting a diagnosis

Supports & services

Are you new to autism & NDIS? We can help.

Family supports

We can also provide support for families

Other supports

Early Years

School Years

School Leavers & Adults

Parents & Professionals

Early years

School years

School Leavers & Adults

Training & Consultancy

Requests for training

Research

Diagnostic referral form

Diagnostic referral form

Person being referred

Guardian (If appropriate)

Referring Person Details

Outline examples of behaviour and responses that are causing concern in the following areas.