Need Urgent Help

Back to top

Neurodivergence Form

Please complete all the details in the form below.

This will help us understand how we can best support your therapy with us.

Questions marked with ‘*’ are compulsory

"*" indicates required fields

DD slash MM slash YYYY

 
This form is for you to be able to share information about your Neurodivergence and to tell us about any adaptations/reasonable adjustments you might need to enable you to access support with your therapy.
 
Please note: We will try our best to meet these adaptations/adjustments with the resources we have available, but specific requests may not always be able to be met. You can complete this form and send it back to us or choose to discuss and fill it out with a member of our team. It is not compulsory and you may choose not to fill it out.
 
My Neurodivergence:*
Please let us know the word you’d like us to use to best describe your Neurodivergence
I prefer to be described as:*

E.g. An Autistic person, A person with ADHD, Dyslexic
My Neurodivergence is an important part of my identity:*
My Neurodivergence has a big impact on my life:*
Please enter a number from 1 to 99.
I prefer to be contacted via:*
I find it easier to receive information:*
I prefer to have appointments via:*
Would you be interested in joining a focus group?
This would be a discussion of different ways we can support individuals with Neurodivergence. This would include practitioners contacting you to discuss, either by email or by phone.