Clone of Provisional Registration [A1]

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Who is the enquiry for?* This field is required.
Myself
Somebody else
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Who is the enquiry for?* This field is required.
An adult (18+)
A young person (16 to 17 years)
A minor (0 to 15 years)
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To ensure we receive accurate information, this form should be completed by the adult seeking our services. If you are enquiring on behalf of someone else, please get in touch and we’ll be happy to advise.
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To ensure we receive accurate information, this form should be completed by (or jointly with) the young person seeking an assessment.
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Depending on the child’s age, we ask that this form is completed by the child’s primary caregiver to ensure the information provided is accurate.
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Your Name* This field is required.
First Name
Last Name
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Name of Person Being Referred* This field is required.
First Name
Last Name
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Your Name * This field is required.
First Name
Last Name
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Relationship (e.g. parent)* This field is required.
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Age of client being referred* This field is required.
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Have you (or the person you are referring) been advised to seek support by a professional?* This field is required.
Yes
No
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You do not need a referral from a professional to access our service. Many people choose to self-refer.
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Who advised seeking professional support services?* This field is required.
Teacher
SENCo
Health Visitor/Nurse
Psychologist/Therapist
Paediatrician
GP
Psychiatrist
Other
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Have you (or the person you are referring) ever engaged in neurodiversity support services previously?* This field is required.
Yes
No
Not Sure
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Please briefly describe outcome:* This field is required.
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Have you (or the person you are referring) ever had any mental health difficulties? Please tick all that may apply:
None
Anxiety
Depression
Trauma-related difficulties
Emotional regulation difficulties
Cognitive Impairment (e.g. memory concerns)
Other
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Please briefly describe:* This field is required.
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Are you (or the person you are referring) currently receiving support from a mental health professional?* This field is required.
Yes
No
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Please briefly describe:* This field is required.
20
Have you (or the person you are referring) had any significant mental health difficulties in the past that have made it difficult to function in every day life e.g. attending school or work?* This field is required.
Yes
No
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Have you (or the person you are referring) ever been hospital admissions related to mental health?* This field is required.
Yes
No
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What year was the latest admission (including A&E visits):* This field is required.
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Have you (or the person you are referring) ever had any history of self-harm or suicidal thoughts?* This field is required.
Yes
No
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When was this last experienced?:* This field is required.
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How long for?:* This field is required.
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Are there any current safety concerns, such as plans or ideas to end your life or harm yourself in anyway?* This field is required.
Yes
No
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If you are experiencing thoughts of suicide or feel that you may be at risk of harming yourself, it’s important to seek immediate support.

You can contact:
• Emergency services (999) if you are in immediate danger
• NHS 111 for urgent advice
• Samaritans on 116 123 (24 hours a day, free of charge)

This service is not able to provide urgent or crisis support, but your responses will be reviewed as part of our triage process.
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Please describe:* This field is required.
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Are you (or the person you are referring) able to communicate verbally in full phrases?:* This field is required.
Yes
No
Sometimes (e.g. context dependent)
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What language(s) do you (or the person you are referring) speak:* This field is required.
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Is the person you are referring aware of this referral?* This field is required.
Yes
No
Sometimes (e.g. context dependent)
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How well do you think they would engage with support services?* This field is required.
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Do you (or the person you are referring) take any medications currently?* This field is required.
Yes
No
Not sure
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Please list name, dose, and who issues the prescriptions:* This field is required.
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Is there any current use of substances (e.g. cannabis)?* This field is required.
Yes
No
Not sure
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Please give details:* This field is required.
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Approximately how many units of alcohol are consumed per week?* This field is required.
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Has there ever been a concern about alcohol dependency?* This field is required.
Yes
No
Not sure
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Please give details:* This field is required.
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What concerns have led you to seek support services at this time?* This field is required.
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Email* This field is required.Communication by email is an essential part of engaging with our service. Please provide an email address that you have sole access to, as our communications may include sensitive information.
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Mobile NumberIf you are happy to be contacted by phone or SMS, please provide a mobile number. Please note that not providing a mobile number may limit certain aspects of our service, such as automated appointment reminders.
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I am happy for my initial appointment to take place (tick all that apply)* This field is required.If you are flexible, selecting both options for your initial appointment may enable availability of earlier appointment times
In Person at Lyndon House Clinic, Sutton Coldfield
By Online Remote Video
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Special needs/accessibility requirementsPlease let us know about any additional needs or accessibility requirements that may be important for our clinicians to be aware about at your appointment. Please describe anything that may cause you to become unwell during an appointment (e.g. allergy, underlying health condition etc)
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Where did you hear about our service?* This field is required.
Please Select
Please Select
GP
Psychologist/Psychiatrist
Other Health Care Professional
Google
Other Search Engine
Social Media
Friend/Family
Word of Mouth
Leaflet
Billboard/Advertisement
Private Health Insurance
Other
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Terms Conditions and Privacy Policy 3.0 [Date {dateOf}]

Please take a moment to review our Privacy Policy and Terms and Conditions so you understand how your information will be used. By submitting this form, you confirm that you have read and agree to our service terms and policies.

West Midlands Autism & ADHD Assessment Service (WMAAAS) works in partnership with Jotform, a secure GDPR compliant data collection service. Information submitted electronically on this form will be sent by a GDPR compliant transmission service and stored securely by WMAAAS. You may wish to print this form for your records. By submitting this form you agree to transfer your data to us securely through Jotform.
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Check the box to confirm:* This field is required.
I have read and agree with West Midlands Autism and ADHD Assessment Service Terms and Conditions and privacy policy 3.0.
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