NEUROVERIFY — REGISTRATION AND APPLICATION FORM

NEUROVERIFY — REGISTRATION AND APPLICATION FORM

Complete this multi-page registration and application form. Follow the section instructions, answer all required questions, and review the UK GDPR and consent information carefully.
Section 1

Personal Details
Section Instructions
Full Name

First NameMiddle NameLast Name
Email Address
example@example.com
Phone Number

Area CodePhone Number
Gender
If self-describe, please specify
Date of Birth

MonthDayYear
Date
Marital Status
Nationality
Current Address

Street Address

Street Address Line 2
CityCountyPostal / Zip Code
Section 2 - Child Registration Only

Parent or Guardian Details (Complete only if registering for a child aged 12 to 17). If not PLEASE GO TO SECTION 3.
Shown only if Q1 selects a child registration option.
Q13. Are you the child's parent or legal guardian?
Q14. Parent/guardian full name

First NameMiddle NameLast Name
Child Date of Birth

MonthDayYear
Date
Q15. Relationship to child
Q16. Parent/guardian phone number
Please enter a valid phone number.Format: (000) 000-0000.
Q17. Parent/guardian email address (If Different From Above)
example@example.com
Q18. Parent/guardian mailing address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Q19. Best time to contact parent/guardian
Q20. Additional guardian or emergency contact details
Q21. Permissions for child registration
Section 3 - Background

Background And Reasons For Applying
Q28. Reason for referral
Q29. Presenting concerns
Q30. Current symptoms

Other
Q31. Onset of concerns
Q32. Previous evaluations or diagnoses reported

Other
Q33. Please specify other previous evaluations or diagnoses
Q34. Current medications
Q35. Areas affected by these concerns

Other
Q36. What would you like NeuroVerify to help determine?
Q37. Any diagnoses previously reported

Other
Q38. Please specify other diagnoses
Section 4 - Medical History

Previous Diagnosis And Medical History
Q39. Does the applicant have any current or past medical conditions that may affect neurodevelopment, learning, or behavior?
Q40. Has the applicant ever been diagnosed with a developmental, learning, behavioral, or neurological condition?
Q41. Please provide details of the diagnosis, including approximate age at diagnosis and any relevant notes.
Q42. Has the applicant received any therapy, intervention, counseling, or special support related to development, learning, behavior, or neurohealth?
Q43. Please list the types of support received, the age range when received, and any relevant details.
Section 5 - Wellbeing And Safety

Wellbeing And Safety
Safety notice: If you are in immediate danger or may act on thoughts of self-harm or harm to others, contact emergency services now or go to the nearest emergency department.

The questions below are asked of everyone — they are not a judgement of you.

They help us ensure you receive the right level of support throughout your screening
Q44. How would you rate your current overall wellbeing?
Q45. Which of the following symptoms have you experienced in the past 2 weeks?

Other
Q46. Have you had any recent changes in your mood or behaviour?
Q47. How often have you been able to carry out your usual daily activities?
Q48. Have you sought any support or care for your current wellbeing concerns?

Other
Q49. Please briefly describe any current stressors or wellbeing concerns.
Q50. Have you experienced any thoughts of harming yourself or others recently?
Q51. If you selected any option other than 'No — I have not had any such thoughts', please provide the relevant details and indicate whether immediate support is needed.
Q52. Do you currently feel able to remain safe while completing this application?
Section 9 - GDPR
UK GDPR and confidentiality notice
Q58. I consent to NEUROVERIFY collecting and processing my personal data for registration and application purposes.
Q59. I understand that my information will be handled in accordance with applicable data protection laws and confidentiality requirements.
Q60. I consent to NEUROVERIFY sharing relevant information with appropriate professionals involved in my care or assessment.
Q61. I understand that information may be shared where required by law, safeguarding, or serious risk concerns.
Q62. I consent to the storage of my information securely for the purposes of this application and any associated services.
Q63. I understand that I may withdraw my consent where applicable, subject to legal and service requirements.
Q64. I confirm that I have read and understood the confidentiality information provided in this form.
Q65. Child registrations only: I consent to the sharing of information with the child’s parent, guardian, or responsible adult as appropriate.
Section 10
Final explanatory or legal text
Q67 – Additional confirmations

Other
Signed By : Enter Name
Should be Empty:

NEUROVERIFY — REGISTRATION AND APPLICATION FORM

Section 1

Section 2 - Child Registration Only

Section 3 - Background

Section 4 - Medical History

Section 5 - Wellbeing And Safety

Section 9 - GDPR

Section 10