If contacting a helpline isn’t for you!

We have included the option to contact us via an online referral form. We have three referral forms for you to use, depending on who you are, as you may be: an individual with ASC, a parent or carer, or a professional or third party. Please check the description above each referral form to find out which is the most suitable for you to complete. Once you have completed the form, please click ‘submit’ and your form will find its way to one of the team. We will then look into your enquiry and contact you once we have sourced the requisite information or support.

Parent/Carer referral form

go to this form

Third Party Referral form

go to this form

Self referral form

Before completing this referral form please note the following: this is a self-referral form for completion by individuals (aged 16+) enquiring about support or information relating to their ASC.

Once we have received your referral, we aim to contact you within 3 working days.

All the following sections must be completed if possible:

Your name

Do you have a formal diagnosis of ASC? Please select one of the following: Do you have a formal diagnosis of ASC? Please select one of the following: Yes No Unsure On waiting list

Briefly explain the reason you are referring yourself to our service -

Your Email address

Your Phone number

Tick to confirm that you live in Derby/Derbyshire? Tick to confirm that you live in Derby/Derbyshire? Yes

Please tick the box below to consent to us contacting you: Please tick the box below to consent to us contacting you: By checking this box you agree for us to contact you

5 + 6 =

If contacting a helpline isn’t for you!

Parent/Carer referral form

Third Party Referral form

Self referral form

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