Provisional Assessment Registration

1
Are you or the person you are referring experiencing a mental health crisis or immediate safety concerns?* This field is required.
Yes
No
2

Please seek urgent support

WMAAAS is not a crisis service. This form is not monitored in real time.

Please stop here and seek urgent mental health or safeguarding support. Contact NHS 111 (option 2), your GP, or in an emergency 999.

You do not need to complete or submit this form. No name or contact details are needed.
3

Before proceeding

✓ We are a private, self-funded autism and ADHD assessment service (not NHS/Right to Choose).

✓ We see adults and school-age children aged 6 or over.

✓ The person being assessed must speak English and participate in the assessment in English.

✓ For children, legal caregivers must be in agreement with this referral.
4
Happy to proceed to register?* This field is required.
Yes
No
5
Please contact us before registering

Contact our administration team to check whether this service is suitable or discuss an appropriate next step.

You do not need to enter personal details or submit this form.
6
Who is this referral for?* This field is required.
Myself (I am aged 16 or over)
My child (0-17 years)
7
Name of the child/young person you are referring* This field is required.
First Name
Last Name
8
Relationship to the person assessed* This field is required.
Parent or legal caregiver
Other supporting adult
Other
9
Your name* This field is required.
First Name
Last Name
10
Age* This field is required.
11
Assessment type enquiry* This field is required.
Autism
ADHD
Autism and ADHD
12
Has there been any form of autism or ADHD assessment previously?* This field is required.
Yes
No
Unsure
13
If yes, please give brief details of the outcome
14
Current mental health* This field is required.
None
Anxiety
Depression
Prefer to discuss
Other
15
Current support from a mental health professional?* This field is required.
Yes
No
16
Have there been significant mental health difficulties in the past?* This field is required.
Yes
No
Unsure
17
Previous attendance to hospital or A&E for mental health related concerns?* This field is required.
Yes
No
Unsure
18
A history of self-harm or suicidal thoughts?* This field is required.
Yes
No
Unsure
19
When was this last experienced?* This field is required.
20
Can you (or the person you are referring) use full sentences verbally?* This field is required.
Yes
No
Other
21
Languages spoken (assessment takes place in English)* This field is required.
22
Medication, alcohol or substances that may affect participation in assessment (state "None" if this not applicable)* This field is required.
23
Presenting concerns* This field is required.Please tell us what has led you to seek our support today
24
Accessibility or health needs, including mobility needs or allergies (or state "none")* This field is required.
This is important so we can ensure we can facilitate your appointment safely
25
Has another professional advised you to seek an assessment? You may self refer* This field is required.
Please Select
Please Select
Self-referral
GP
Paediatrician
Psychologist or psychiatrist
School or educator
Other
26
Referral details (if not self-referral)
27
Email address* This field is required.
example@example.com
28
Contact phone number* This field is required.
Please include the best number to contact you. UK or international numbers are accepted.
29
Appointment preference* This field is required.
In person
Online
Either
30
Whilst Phase 1 can be conducted online, the second phase of our assessments always contain in-person components.
31
Where did you hear about us* This field is required.
Please Select
GP
Psychologist/Therapist
Other healthcare professional
Google
Facebook/Instagram/Social Media
A recommendation (word of mouth)
Leaflet/Flyer
Billboard
Teacher/School/SENCo
Other
32
What happens next

✓ Sign the terms and pay for Phase 1.

You will be redirected to our terms and conditions and payment link.

✓ We review your registration.

Once we receive your signed terms and payment, our team will review whether the service can meet your needs.

✓ A full refund if we cannot offer the service.

If this review shows that our service is not suitable, we will explain why and refund your payment in full before an appointment is offered.
33

✓ Book after your registration is accepted.

Registration does not confirm an appointment. If you can proceed following our review, we will give you access to the client portal and booking system.

✓ Decide about Phase 2 later.

Paying for Phase 1 does not commit you to a full diagnostic assessment. We only request Phase 2 payment once we have assessed it as suitable and you have chosen to continue.

✓ Phase 1 is non-refundable once completed.

This applies even if a full assessment is not suitable at that time. We will explain the clinical reasons and provide advice about other support or next steps.
34
Consent* This field is required.
I confirm that I have read the WMAAAS Privacy Policy (https://www.wmaaas.co.uk/privacy-policy) and consent to the information provided in this form being securely submitted to West Midlands Autism & ADHD Assessment Service Ltd (WMAAAS) for the purposes outlined in the Privacy Policy.
Should be Empty:

Please seek urgent support

Before proceeding

Please contact us before registering

What happens next