Booking Form

Please only complete this booking form if you have been sent this link directly from Adélie Psychology.

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Your booking form has been submitted

Name

Date of Birth (DD/MM/YYYY)

Full Address including Postcode

Parent/carer with Parental Responsibility (required for under 18s)

Phone

GP Surgery

Which service are you booking?(required)

Autism assessment + ADHD assessment (only available for children aged 6 to 18 years old when having an autism assessment) + Cognitive assessment (only available for children aged 6 to 17 years old when having an autism assessment) + Adaptive functioning assessment (only available for children and young people aged 3 to 21 years old when having an autism assessment) Speech and language assessment Art Therapy Talking Therapy

Please indicate how fees will be paid (choose one option)

Please complete the following for under 18s:

Nursery/School/College (required for under 18s)

Name of Contact in Education Setting who knows your child the best (required for under 18s)

Email of Contact in Education Setting (required for under 18s)

Please complete the following for over 19s:

For autism assessments over the age of 19, please indicate if you would like your parents to be involved in your assessment, and if so, please include their contact details in the other details section below

Yes

Please complete if you have Private Healthcare Insurance:

Private Healthcare/Medical Insurer

Membership Number

Preauthorisation Number

Limits of Funding (number of sessions/amount of funding)

Excess

Expiry/renewal date of policy (DD/MM/YYYY)

Everyone to complete

How did you hear about us?

Other Details