Adult Referral

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Adult Referral

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Adult Referral

We charge a £95 non-refundable booking fee at the point of referral (which can be made by you or a professional). This initial fee will be deducted from the initial screening fee.

Adult Referral

Type of referral:

Autism assessment

ADHD assessment

Combined assessment

Name of client to be assessed:

D.O.B.

Gender at birth:

Male

Female

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Address

Street address:

City:

County:

Post code:

Email (person filling out form):

Your phone number:

If you are a parent/carer of a young adult aged 18 to 21 enquiring on their behalf, we will need their explicit consent before organising any assessments. Please provide their email address and mobile number:

If young adult is in full time education, please include a school/college/university email address and contact details as questionnaires need to be sent directly:

Reason for Referral (please indicate what the main concerns that have led to this referral are, and what you feel the impact is – on you, work, relationships etc.):

Please provide name(s) and email address/addresses for invoices:

Additional Invoicing information: e.g. Invoice to be split 50/50:

How did you hear about us? (tick all that apply)

Magazine Advert

Online Advert

Search Engine (i.e. Google)

Recommendation

Social Media

Word of Mouth

Other (Please specify)

If 'Other' or 'Recommendation' above, please provide further details:

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In submitting this enquiry you agree that your data will be processed in accordance with our privacy policy.

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Questions?

Get in touch with our team to find out more:

admin@berkshirepsychology.co.uk

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Phone:

Email:

Message:

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We're based a short drive from Reading with on-site parking.

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