FPG ADA Service Consent

ADA Service Acknowledgement & Consent

NHS and Private
Date*

DayMonthYear
Date
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:*

Myself (Over 18)A Child (under 18)
My assessment is being funded by*

NHS/ CCGPrivate (You)EmployerOther
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
Relationship to individual being assessed
Full Name*

First NameLast Name
Date of Birth

DayMonthYear
Email Address*
example@example.com
Mobile Number*
Mobile Number
Client Information

Please complete the following fields regarding the individual being assessed
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
NHS Number
If Known
Email Address*
example@example.com
Mobile Number*

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.
Assessment Location*
For face to face appointments please choose your preferred location. Please note that availability may vary depending on location.
Please indicate which assessment is most relevant

Child (7-10)Young Persons (11-21)Adult (22+)
Base Assessment Fee
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.

ADHD Screening (£295)PDA Screening (£295)Cognitive / Executive Functioning Assessment (£395)Learning Disability Assessment (£595)Trauma / PTSD Assessment (£595)
£ Assessment Total

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.
Name

First NameLast Name
Email

Confirmation EmailWe use encrypted email to send all letters and reports
In a few words, please explain what you hope to achieve by having an assessment for ASD
We like to know this so we can tailor your report with recommendations we feel appropriate.

Payment Options

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

Debit/Credit CardInvoicePayment PlanInsurance Policy (eg.Bupa/AXA)
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.
Insurance Company
Please choose fwhich insurer you are with
Policy / Member Number
Please provide your member or policy number
Authorisation Code
If you have been provided with an authorisation code please provide this here. If you dont have an authorisation code or you have confirmation of funding another way, you must contact the Case Management Team.

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 accept, please proceedI don't accept
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 accept, please proceedI don't accept
I confirm I am the representative of the client being assessed and would like to proceed with an Autism Diagnostic Assessment.*

I accept, please proceedI don't accept
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*

I accept, please proceedI don't accept
Please provide your signature below*

Clear
Should be Empty:

ADA Service Acknowledgement & Consent

Your Information

Client Information

Assessment Options

Child and Young Person's Assessment

Report Options

Consent Options

Payment Options

Confirmation