Adult Autism Questionnaire

To help us send your right to choose referral quickly and accurately, please complete the questions within this form.

• Please provide information below as to why you feel an assessment for Autism is required. It is essential you include any:

1. Presenting difficulties suggestive of Autism
2. Evidence that symptoms were present in childhood/adolescence
3. Resultant impairments in school/work/at home

• For a Right to Choose Autism assessment, some providers require a questionnaire to be done prior to the referral (AQ-10).  Please could you give us a copy of this questionnaire if your provider requires it, if not – please complete the following questions.
• Please note that the AQ-10 questionnaire on this page is for adults only. If this referral is for your child and the provider you have selected does not have any questionnaire, there is no need to do anything else besides answer the following questions.