The Navigation Questionnaire Form
Answer a short set of questions to help us understand your situation and suggest suitable assessment pathways before your online appointment.
About the Person Seeking Assessment
Who is the appointment for?
*
Myself
My child or young person
Another adult I support
Full name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home postcode
*
Email address
*
example@example.com
Telephone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
If you selected “Another adult I support”, provide your details
Reason for Seeking Help
What would you like help understanding?
*
ADHD
Autism
Both ADHD and autism
Unsure and would like guidance
What prompted you to seek help now?
*
Where do your difficulties have the greatest impact?
*
School
College
University
Employment
Home/family life
Relationships
Emotional wellbeing
Organisation/everyday functioning
Social interaction
Other
Current NHS / Referral Position
Have you spoken to your GP about an assessment?
*
Yes
No
Not yet
Prefer not to say
Have you already been referred for an NHS ADHD or autism assessment?
*
Yes
No
Not sure
Prefer not to say
Which NHS service or provider were you referred to?
Approximate referral date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently on any other neurodevelopmental waiting list?
ADHD assessment
Autism assessment
Speech and language assessment
Occupational therapy assessment
Educational psychology assessment
Other
Previous Diagnoses and Assessments
Previous diagnoses or conditions
*
ADHD
Autism
Dyslexia
Dyspraxia / DCD
Learning disability
Developmental language / communication difficulties
Anxiety
Depression
Another mental health condition
Another developmental / learning condition
None
Unsure
Have you previously had an ADHD or autism assessment that did not result in a diagnosis?
*
Yes
No
Unsure
If yes, please briefly tell us about that assessment
ADHD Indicators
ADHD indicators
Which of the following ADHD-related difficulties apply?
Concentration / maintaining attention
Easily distracted
Forgetfulness
Losing belongings
Organisation / time management
Starting tasks
Completing tasks
Procrastination
Restlessness / fidgeting
Constantly on the go
Excessive talking
Interrupting others
Acting before thinking
Difficulty waiting
Emotional regulation difficulties
None of these
Were these difficulties present in childhood?
Yes
No
Unsure
Person is currently a child
Briefly describe your main ADHD concerns
Autism Indicators
Which of the following apply to you?
*
Understanding social situations
Making or keeping friendships
Reading social cues
Conversation or social communication
Feeling different from others
Masking or copying social behaviour
Need for routine or predictability
Difficulty with change
Intense interests
Repetitive behaviours or movements
Sensitivity to noise, light, touch, clothing, textures or food
Feeling overwhelmed in busy environments
None of these
Were these differences noticeable in childhood or early development?
*
Yes
No
Unsure
Person is currently a child
Please describe your main autism-related concerns
*
Do you find understanding social situations difficult?
Yes
No
Sometimes
Unsure
Do you find it hard to make or keep friendships?
Yes
No
Sometimes
Unsure
Do you struggle to read social cues?
Yes
No
Sometimes
Unsure
Do you find conversation or social communication difficult?
Yes
No
Sometimes
Unsure
Do you often feel different from other people?
Yes
No
Sometimes
Unsure
Do you mask or copy social behaviour to fit in?
Yes
No
Sometimes
Unsure
Do you prefer routine or predictability?
Yes
No
Sometimes
Unsure
Do you find change difficult?
Yes
No
Sometimes
Unsure
Do you have intense interests?
Yes
No
Sometimes
Unsure
Do you have repetitive behaviours or movements?
Yes
No
Sometimes
Unsure
Are you sensitive to noise, light, touch, clothing, textures or food?
Yes
No
Sometimes
Unsure
Do busy environments feel overwhelming?
Yes
No
Sometimes
Unsure
Do any of these not apply to you?
Yes
No
Children and Young People
School or college attended
Support in place
SEN Support
EHCP
Alternative Provision
Specialist provision
Reasonable adjustments
None
Unsure
Other
Has the school or college raised concerns?
*
Yes
No
Unsure
If yes, please give brief details
Is education significantly affected?
*
Yes
No
Unsure
Upload school report, SENCO letter, EHCP, or previous assessment report
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Adults
Current situation
*
Employed
Self-employed
University/college
Unemployed
Unable to work
Other
How do these difficulties affect your work, study, or day-to-day responsibilities?
*
GP and Right to Choose
Are you registered with an NHS GP in England?
*
Yes
No
Unsure
GP practice name
GP practice town or postcode
Note: GP practice information helps us explore NHS and Right to Choose options, but referral acceptance, eligibility, and provider availability cannot be guaranteed.
Hoped-for Outcome
What would you like to understand or achieve?
*
Find out whether a free NHS/Right to Choose assessment may be available
Understand whether an ADHD assessment may be appropriate
Understand whether an autism assessment may be appropriate
Understand whether both should be considered
Understand private assessment options
Get help approaching my GP
Understand what to do while already on a waiting list
Unsure and would like professional guidance
Is there anything particular you would like to discuss?
Safety
Are there any immediate concerns about safety or wellbeing?
*
No
Yes
If yes, please briefly describe the concerns
Safety notice: This service is not an emergency or crisis service. If there is immediate danger or an urgent mental health concern, contact emergency services or an appropriate urgent healthcare service now.
Consent
Confirmations
*
I understand this is pre-assessment screening, guidance and pathway navigation only, and not a diagnostic assessment.
I understand that identifying a potential Right to Choose or NHS route does not guarantee referral acceptance, eligibility or provider availability.
I confirm that the information provided is accurate to the best of my knowledge.
Consent to Use Information
*
Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service Provider
Additional Comments
Submit
Submit
Should be Empty: