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Autism Client Questionnaire
Read Privacy Statement
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Yes
No
Privacy Statement
We are Disability Counselling Specialists, and we are responsible for protecting your information. We collect your personal details (like your name and postcode) and sensitive health information (like your diagnosis and how it affects you) to understand your needs and provide you with the right support. We store your data securely and keep it confidential. We will not share your health information with anyone else unless you give us clear permission. For example, if you want an NHS application, we will need your permission to send a funding application and a full mental health report all about you to your GP; this enables us to apply for funding for you. You have the right to ask to see, correct, or delete your information at any time.
You are?
First Name?
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Surname Name ?
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Home Postcode
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Date of birth
GP Practice?
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GP Practice Name
Have you had NHS Counselling Previously?
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Yes
No
Other
Have you had NHS Counselling Previously?
What are you referring for?
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NHS Funded Sessions
Self-Pay
Self-Pay to Start with NHS Application
Other
What are you referring for?
Confirmation you have had NHS funded counselling in the last 2 years
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Yes
No
Other
Confirmation you have had NHS funded counselling in the last 2 years
Important: NHS Funding Assessment
To apply for NHS funding for your counselling, please read this. If you have not had any NHS-funded counselling in the last 2 years, you must first get a new mental health assessment from your local NHS mental health service. Please email us and ask for the “NHS self-referral link”. We will send you the correct link so you can contact them directly. Important: If the NHS service assesses you and then discharges you because they feel your case is “too complex”, please let us know. At that point, we can then make the funding application for you.
Neurodiverse Identification
Professionally diagnosed?
No
ADHD
Aspergers
Autistic disorder
DLD
Dyslexia
RET
Kanner’s
pervasive disorder
If yes, with which?
Diagnosed by who?
GP
Neurologist
Other
Other
What year were you diagnosed?
If don’t know the exact year, approx is suitable
Have you got a history of a neuro-developmental conditions
History – Multi-Select
No
Learning disabilities
Attention deficit hyperactivity disorder
Psychiatric difficulties
DLD (Developmental Language Disorder)
Struggling to learn new words or put words into sentences
No
Yes
Difficulty following directions
No
Yes
Making frequent grammatical errors
No
Yes
Limited use of complex sentences
No
Yes
Difficulty finding the right words
No
Yes
Reading and writing problems
No
Yes
Disorganised storytelling
No
Yes
How, Does Autism or ADHD Effect You?
Behaviours- Multi-Select
Prefer consistent routine and schedules
Upset when something happens that you did not expect to happen
Have trouble regulating your emotional responses.
Are bothered if your things are moved or rearranged by someone
Get upset or anxious should that routine or schedule be changed.
Have a series of repetitive rituals or behaviours
You make noises in places where you are expected to be quiet
Preference for highly specific interests or hobbies
Have difficulty multi-tasking
Have a very strong reaction or no reaction to smell
Like operating solo – both at work and play.
Have a very strong reaction or no reaction to noise
How Does It Impact You?
Impact – Multi-Select
Problems in obtaining, regularly attending or sustaining employment or education.
Difficulties in initiating or sustaining social relationships.
If you are human, leave this field blank.
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