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.

Self referral form

Third Party Referral form

Carer/parent referral form

Before completing this referral form please note the following: This referral form is for completion by carers or parents of individuals with ASC enquiring about support for themselves. If you are a carer or parent and wish to enquire about support for someone else, please telephone our help-line.

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

Does the individual you care for/parent have a formal diagnosis of ASC? Please select one of the following:

Please tick the below box to confirm you live in Derby/Derbyshire

Please tick the box below to consent to us contacting you:

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