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Autism assessment self referral form and Autism Spectrum Quotient (AQ)-50: Screening Questionnaire

Please note that in order to access the Adult Autism Assessment Service via self referral the person seeking assessment needs to be registered with a GP in Derby or Derbyshire. We cannot accept self referrals for people who are not registered with a Derby or Derbyshire GP. If you do not have a Derby/Derbyshire GP please contact your GP for advice regarding accessing an assessment in your area.

Personal information

Required
Date of birth Required
Required
Address Required
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Required
Required
Are you an Armed Forces Veteran? Required
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Required
Required

AQ50

  • Read each of the statements very carefully
  • There are no right and wrong answers
  • Put a tick in the box to rate how strongly you agree or disagree with the statement
  • Do not miss out any statements
1. I prefer to do things with others rather than on my own Required
2. I prefer to do things the same way over and over again Required
3. If I try to imagine something, I find it very easy to create a picture in my mind Required
4. I frequently get so strongly absorbed in one thing that I lose sight of other things Required
5. I often notice small sounds when others do not Required
6. I usually notice car number plates or similar strings of information Required
7. Other people frequently tell me that what I've said is impolite, even though I think it is polite Required
8. When I'm reading a story, I can easily imagine what the characters might look like Required
9. I am fascinated by dates Required
10. In a social group, I can easily keep track of several different people's conversations Required
11. I find social situations easy Required
12. I tend to notice details that others do not Required
13. I would rather go to a library than a party Required
14. I find making up stories easy Required
15. I find myself drawn more strongly to people than to things Required
16. I tend to have very strong interests which I get upset about if I can't pursue Required
17. I enjoy social chit-chat Required
18. When I talk, it isn't always easy for others to get a word in edgeways Required
19. I am fascinated by numbers Required
20. When I'm reading a story, I find it difficult to work out the characters' intentions Required
21. I don't particularly enjoy reading fiction Required
22. I find it hard to make new friends Required
23. I notice patterns in things all the time Required
24. I would rather go to the theatre than a museum Required
25. It does not upset me if my daily routine is disturbed Required
26. I frequently find that I don't know how to keep a conversation going Required
27. I find it easy to 'read between the lines' when someone is talking to me Required
28. I usually concentrate more on the whole picture, rather than the small details Required
29. I am not very good at remembering phone numbers Required
30. I don't usually notice small changes in a situation, or a person's appearance Required
31. I know how to tell if someone listening to me is getting bored Required
32. I find it easy to do more than one thing at a time Required
33. When I talk on the phone, I'm not sure when it's my turn to speak Required
34. I enjoy doing things spontaneously Required
35. I am often the last to understand the point of a joke Required
36. I find it easy to work out what someone is thinking or feeling just by looking at their face Required
37. If there is an interruption, I can switch back to what I was doing very quickly Required
38. I am good a social chit-chat Required
39. People often tell me that I keep going on and on about the same thing Required
40. When I was young, I used to enjoy playing games involving pretending with other children Required
41. I like to collect information about categories of things (e.g. types of cars, birds, trains, plants, etc.) Required
42. I find it difficult to imagine what it would be like to be someone else Required
43. I like to plan any activities I participate in carefully Required
44. I enjoy social occasions Required
45. I find it difficult to work out people's intentions Required
46. New situations make me anxious Required
47. I enjoy meeting new people Required
48. I am a good diplomat Required
49. I am not very good at remembering people's dates of birth Required
50. I find it very easy to play games with children that involve pretending Required
Required


Next steps

Once we receive your referral, the AQ50 will be scored and your clinical information will be reviewed. If it meets our criteria to be offered an NHS assessment you will be sent a number of questionnaires to complete to aid the assessment process. Please note: It is important that you complete and return these questionnaires.  We can offer reasonable adjustments for people who struggle with filling in forms.

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