Clone of Provisional Registration [A1]

1
Are you referring a person that meets our minimum age requirement for assessments?* This field is required.We see adults and children. For ADHD assessments, children must be aged 6 or over. For autism assessments school-age children under the age of 6 must be referred by a paediatrician.
YESNO
2
Are you or the person you are referring experiencing a mental health crisis or safety concerns?* This field is required.A mental health crisis is a situation in which a person’s emotional or psychological distress becomes so severe that they may be unable to cope safely or may be at risk of harming themselves or others.
YESNO
3
Are you aware that we are a private provider and are not funded by the NHS or Right to Choose?* This field is required.
YESNO

Before proceeding

Please make sure you understand the following key information about our service.

✓	We are a private service and are not an NHS or Right to Choose provider.
✓	You do not need a GP referral and can self-refer.
✓	We assess children, young people and adults for autism and ADHD. Children must be school-age, and for ADHD assessment must be aged 6 or over.
✓	We are not an emergency or crisis service and may not be suitable where there are immediate or significant mental health or safeguarding concerns.
✓	For children, we require information from an educator or another independent adult who knows the child well, such as a teacher, tutor or group leader.

How the assessment works

Our staged pathway helps us decide what is most appropriate before you incur the cost of a full diagnostic assessment.

✓	Phase 1 is the first clinical stage and helps us consider the most appropriate assessment pathway.
✓	Progression beyond Phase 1 is not automatic. We may recommend further assessment, a different pathway or another service.
✓	A diagnostic outcome can only be reached once the required stages of assessment have been completed.
✓	Where there is a significant history of mental health or wider family needs, we may ask during Phase 2 for your GP to be involved in a coordinated care arrangement. This will always be discussed with you first.

When another pathway may be more appropriate

Phase 1 also helps us consider whether our service can safely and effectively meet the needs identified.

✓	Where assessment would require substantial ongoing liaison, coordination or risk management, another service may be better placed to provide the level of support required.
✓	We may recommend pausing or redirecting the pathway where reliable participation in the assessment process is unlikely to be possible.
✓	We may also recommend that another health, psychological, social or safeguarding need is addressed first where this should reasonably take priority.
✓	Where possible, we will explain our recommendation and help identify an appropriate next step.

7
Following review of our service information would you still like to proceed to submit a provisional registration?
YESNO
8
Who is the enquiry for?* This field is required.
Myself
Somebody else
9
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)
10
To ensure we receive accurate information, this form should be completed by the adult seeking an assessment. If you are enquiring on behalf of someone else, please get in touch and we’ll be happy to advise.
11
To ensure we receive accurate information, this form should be completed by (or jointly with) the young person seeking an assessment.
12
Depending on the child’s age, we ask that this form is completed by the child’s parent or legal caregiver to ensure the information provided is accurate.
13
Your Name* This field is required.
First Name
Last Name
14
Name of Person Being Referred* This field is required.
First Name
Last Name
15
Your Name * This field is required.
First Name
Last Name
16
Relationship (e.g. parent)* This field is required.
17
Age of client being referred* This field is required.
18
Please indicate which assessment(s) you are hoping to pursue* This field is required.
Autism
ADHD
Unsure
Other
19
Have you (or the person you are referring) been advised to seek an assessment by a professional?* This field is required.
Yes
No
20
You do not need a referral from a professional to access our service. Many people choose to self-refer.
21
Who advised assessment?* This field is required.
Teacher
SENCo
Health Visitor/Nurse
Psychologist/Therapist
Paediatrician
GP
Psychiatrist
Other
22
Are all caregivers with legal parental responsibility aware and in agreement with an assessment for Autism/ADHD?* This field is required.
Yes
No
23
Have you (or the person you are referring) ever had a previous assessment for autism or ADHD?* This field is required.
Yes
No
Not Sure
24
Please briefly describe outcome:* This field is required.
25
Have you (or the person you are referring) ever had any current mental health difficulties? Please tick all that may apply:* This field is required.
None
Anxiety
Depression
Trauma-related difficulties
Emotional regulation difficulties
Cognitive Impairment (e.g. memory concerns)
Other
26
Are you currently receiving support from a mental health professional?* This field is required.
Yes
No
27
Have you (or the person you are referring) had any significant mental health difficulties in the past?* This field is required.
Yes
No
28
Have you (or the person you are referring) ever had a hospital admission related to mental health?* This field is required.
Yes
No
29
What year was the latest admission (including A&E visits):* This field is required.
30
Have you (or the person you are referring) ever had any history of self-harm or suicidal thoughts?* This field is required.
Yes
No
31
When was this last experienced?:* This field is required.
32
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)
33
What language(s) do you (or the person you are referring) speak:* This field is required.
34
Is the person you are referring aware of the assessment?:* This field is required.
Yes
No
Other
35
How well do you think they would engage with an assessment?* This field is required.
36
Do you (or the person you are referring) take any medication or substances (e.g. drugs or alcohol) that could influence your participation in an assessment, behaviour or cognition?* This field is required.
Yes
No
Not sure
37
Please describe* This field is required.
38
What concerns are leading you to seek assessment at this time?* This field is required.
39
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.
40
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.
41
I am happy for my initial appointment to take place (tick all that apply)If you are flexible, selecting both options for your initial appointment may enable availability of earlier appointment times. Please note that an in-person visit to Lyndon House is necessary for Stage 2 full diagnostic assessment.
In Person at Lyndon House Clinic, Sutton Coldfield
By Online Remote Video
42
Special needs/accessibility requirements* This field is required.Some of our clinic rooms are accessible via stairs. Please let us know about any additional needs or accessibility requirements that may be important for us to understand. Please describe anything that may cause you to become unwell during an appointment (e.g. allergy, underlying health condition etc)
43
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
44
Tick to confirm agreement with data transfer:
West Midlands Autism & ADHD Assessment Service (WMAAAS) works in partnership with Jotform, a secure GDPR compliant form 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.
Should be Empty: