FPG ADA Service Consent

  • ADA Service Acknowledgement & Consent

    NHS and Private
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  • We are pleased that you have decided to proceed with an Autism Diagnostic Assessment with us.  To enable us to move forward we need you to confirm a few details. 

    Please make sure you have received both your post consultation letter and the "ADA The Next Stage" letter as this contains important information regarding your assessmnet. 

    One this form is submitted, one of our Case Managers will be in contact with you to discuss your appointments.

  • I am completing this form for:*
  • My assessment is being funded by*

  • NHS Funded Assessments

    Please note we do not currently hold any live contracts with the NHS and so we will require written confirmation that your referral is being funded before proceeding.

  • Your Information

    Please complete the following fields about you
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  • Client Information

    Please complete the following fields regarding the individual being assessed
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  • Assessment Options

    Optional Assessments can be included with your Autism Diagnostic Assessment and often offer a saving on the stand alone fees.

  • We have developed core and optional assessments depending on the age of the individual being assessed. The core assessments are considered to be the minimum needed to formulate a diagnosis. More information on our core and optional assessments can be found on our website.

    The optional assessments may have been recommended to you either in your post consultation letter or by a member of the Autism Diagnostic Assessment Team.  

    Below are the optional assessment choices available.  Please confirm below the optional assessments you would like us to include.  If we have not included these on your estimate of fees we will need to send you a revised estimate before proceeding. This will be sent to you separately by email. 

  • Please indicate which assessment is most relevant
  • Please confirm the optional assessments you would like us to include in your assessment. Please note that the additional assessments below are charged in addition to the main assessment service fee. If you select any of the options below a revised estimate will be sent out to you within 24 hours.

  • Child and Young Person's Assessment

    As your child is aged between 5 and 17 we need to ask a few more questions. This will help inform who is part of the diagnostic assessment team.
  • Do you have any CURRENT concerns regarding your child's speech and language development
  • Has your child at any age, experienced a regression in language or motor skills?

  • As you have indicated that your child has experienced a regression in language or motor skills, you must be referred to a paediatrician or paediatric neurologist in the first instance.  This is to ensure any assessment is administered in accordance with NICE Guidelines.  

     

    Before proceeding, please contact a Case Manager to discuss this further.

  • Is your child currently or has previously been assessed by a Speech and Langauge Therapist?
  • Is your child currently or has previously received input/support from CAMHS?
  • Is your child currently or has previously been assessed by an Educational Psychologist?
  • Is your child currently or in the past 3 years been seen by any other medical practitioner?

  • Report Options

    Please tell us who we should send your post assessment summary letter and full diagnostic report to. Please note that your letter and report will be sent using encrypted email in PDF format.

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  • Consent Options

    Please consider each of the statements below and confirm your consent options with us
  • I give consent for The Family Practice Group to contact my Doctor (GP) and request a copy of my medical records / notes.
  • I give consent for The Family Practice Group to contact my child's Doctor (GP) and request a copy of their medical records / notes.

  • If we require medical / clinical history, you will be sent a link via email to complete a seperate consent form.  This seperate form will be sent to your GP.

  • I give consent for The Family Practice Group to contact my child's school / college to inform them of the assessment and to invite them to contribute to the assessment by providing them with additional information.

  • NICE clinical guidelines recommend that any assessment for Autism involving a child or young person involves their school or college.  This is so the assessment team may gather as much information as possible.  If your child is current home schooled or has not attended school for 3 months or longer then please contact the Case Management Team so we may discuss how best to proceed. 

  • [ADULTS] I give consent for The Family Practice Group to contact my nominated close friend or relative and send them a self assessment pack to complete. Your assessment results will not be discussed with them.

  • Nursery/School/College

    You have chosen to give us consent to contact your child's nursery/school/college. As part of the assessment we would like to send them some self assessments online to complete.  Please provide the name of your child's teacher, form tutor or SENCO, or the most appropriate person who knows your child well.

     

  • Adult Relative / Close Friend

    You have chosen to give us consent to contact a close friend or relative to assist us with your assessment.  This involves sending them a self assessment pack to complete so that we can gather further information about you.

    Your assessment results will not be discussed with them.  

    We often need to send them assessments via email and by post.  We can provide these to you to give to them if you prefer but we do require an email address to send the assessments that can only be sent via email.

     

  • How do you know this person?

  • IMPORTANT

    You have chosen not to give us consent to contact your child's school. 

    Whilst we will respect your decision we may not be able to provide you with a definitive outcome with regards to the assessment.  This is because the guidelines for assessing children for ASD include obtaining information from other professionals including their school.

    If we are unable to provide you with a definitive outcome you will still be charged the full assessment fee.

  • I give consent for a copy of the post assessment summary letter and a copy of the diagnostic report to be sent to the registered Doctor (GP).

  • Payment Options

    The total cost of your assessment is shown below. Please confirm how you would like us to charge for your assessment.
  • Please select a payment option*

  • Debit or Credit Card

    As you have elected to pay for your assessment using a debit or credit card we will shortly send you an invoice containing a payment link where you may submit payment.

     

    Payment will be required once appointments are confirmed.  If payment is not received 24 hours following confirmation of your appointment they may be released to other clients.

     

    As soon as your form has been recieved, one of our Case Managers will contact you to discuss your appointment(s) and we will send you the self and informant assessment by post and email to get your assessment started straight away.

     

    Please note we are unable to send you any self or informant assessments until payment has been received.

     

  • Payment Plan

     

    Before we can offer you any appointments you will need to complete our Payment Plan Application Form, available on our website at https://www.familypracticegroup.co.uk/payment-plan 

    As soon as your payment plan has been agreed we can proceed by offering you an appointment and sending you out the self and informant assessments that we need completing prior to your appointment.

  • Payment by Invoice

    As you have elected to pay for your assessment by invoice we will send this to you by email.

     

    Payment will be required once appointments are confirmed.  If payment is not received 24 hours following confirmation of your appointment they may be released to other clients.

     

    As soon as your form has been recieved, one of our Case Managers will contact you to discuss your appointment(s) and we will send you the self and informant assessment by post and email to get your assessment started straight away.

     

    Please note we are unable to send you any self or informant assessments until payment has been received. 

  • Medical Insurance

    If you have a medical insurance policy with Bupa or AXA for example and they have authorised, you to proceed you will need to provide a few more details.

     

    Please note, that clients are fully responsible for all fees at all times.  We will invoice your insurer following your first appointment with us.  We will need to receive full payment prior to releasing your diagnostic report.  If your insurer fails to settle your fees in full you will need to pay any outstanding fees prior to receiving your report.

     

    Please ensure you have read and understood the terms of your policy correctly as often clients may have an excess to pay which your insurer will ask us to collect.

  • Confirmation

    Please confirm the statement below and if you would like to proceed please sign and submit the form below.
  • I would like to proceed with an Autism Diagnostic Assessment for myself and confirm I have received and accepted the General Terms and Conditions and read the letter "ADA Proceeding with an assessment" in full.*
  • I confirm I am the parent or legal guardian of the child being assessed and would like to proceed with an Autism Diagnostic Assessment. I confirm I will be responsible for any fees due including any applicable cancellation fees as set out in the General Terms and Conditions. I further confirm that there is no ongoing court proceedingsor legal basis that would otherwise prevent me from authorising the practice to deliver such an assessment.*
  • I confirm I am the representative of the client being assessed and would like to proceed with an Autism Diagnostic Assessment.*
  • I understand that I am instructing the Family Practice Group to administer a full diagnostic assessment for Autism Spectrum and to provide (if appropriate) a clinical diagnosis of Autism Spectrum Disorder. I understand and accept that should the clinical team find that I / my child do not meet the clinical threshold for this condition, I will not be provided with a diagnosis*
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