Consent form


Please be aware at this time we can only accept referrals completed by professionals and cannot accept self referrals or referrals made by parent/carers. Please discuss this referral with education/health professionals.

You must provide a valid name.
You must provide an answer to this question.
You must provide a valid name.


I understand that my/our child has been referred to Alder Hey’s Developmental Paediatric Services which includes: Autism Spectrum Pathway, ADHD services & Developmental Paediatrics. This referral has been fully explained to me/us. I/We understand that following the assessment outcome, my Child/Young Person may be given a diagnosis of autism spectrum disorder / pathological demand avoidance profile. I agree that I fully understand this and consent for the assessment to take place. 


I/We give permission for the Alder Hey’s Developmental Paediatric Services to undertake assessments as appropriate.  Permission is also given to gather, discuss & share applicable information in respect to my/our child’s assessment within the team & appropriate outside agencies.  Where applicable, this may include:


School and SENCO; including
School observations
Clinical Psychology
Educational Psychology Service
Alder Hey/Hospital Contact
Occupational Therapy Service 
ADDvanced Solutions Community
Speech and Language
Therapy Service
Health Visitor
Social Worker, Social Services
Child and Adolescent Mental Health Services 
Learning Disability Team
ASD Training Team
Other e.g.  Children’s Centre, Children’s Services
Youth Justice Team


I/We understand that  parents/carers/guardians who have parental responsibility are required to give consent for an assessment to be completed.  If parents have joint parental responsibility, we understand that both parents are required to agree to assessment. However, we understand that an assessment can be progressed with  informed consent from one legal guardian.


I/We understand that if my Child/Young Person person is cared for fully or partially by the local authority that the supervising social worker will need to counter sign the referral form.


Once all assessments are completed I/ We may be invited to opt in for a feedback session. I/We understand attending the feedback session, if invited, is strongly advised as the outcome of the assessment will be discussed.  I/We agree it is in the child’s best interest that the feedback session is attended, if invited.


If I/We do not attend the feedback session as advised or make any contact with the Team to discuss this matter a copy of the report containing the outcome of the assessment will be sent to my/our address & GP.


I/We understand that demographic data in relation to my child will be shared with ADDvanced solutions community network so they are able to communicate we us in regard to training / events that are taking place. (this is only for referrals to the Autism Spectrum Pathway)


I/We understand that information concerning risk of harm to a Child/Young Person must always be shared for safeguarding reasons. 


This form has been fully explained to me.


I can confirm I have read the above and give my consent as legal guardian.


Name of person or persons with parental responsibility:

You must provide an answer to this question.
You must provide a valid name.
You must provide a valid name.
You must provide a valid name.