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. Which one you use depends on who you are, as you may be an autistic individual, a parent or carer, a professional or a 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 it’s way to one of the team. We will then look into your enquiry ad contact you once we have sourced the requisite information or support.

Self referral form

go to this form

Carer/Parent Referral form

go to this form

Professional/Third Party
referral form

Before completing this referral form, please note the following: this referral form is for completion by a professional or third party affiliated with an autistic individual enquiring about support for themselves. If you wish to enquire about support for someone else, please telephone our helpline.

If you are a professional seeking training or awareness raising relating to autism to be implemented in your own organisation or service, please contact our service via the enquiries box or email address provided, detailing your requirements.

All the following sections must be completed if possible:

Your name

Your profession and name of organisation -

Does the individual you are in contact with have a formal diagnosis of ASC? Please select one of the following: Does the individual you are in contact with have a formal diagnosis of ASC? Please select one of the following: Yes No Unsure On waiting list

Reason you are making this referral –

Your Email address

Your Phone number

Tick the box below to confirm the person who requires support lives in Derby/Derbyshire? Tick the box below to confirm the person who requires support lives 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

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If contacting a helpline isn’t for you

Self referral form

Carer/Parent Referral form

Professional/Third Party
referral form

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If contacting a helpline isn’t for you

Self referral form

Carer/Parent Referral form

Professional/Third Partyreferral form

Professional/Third Party
referral form