Needs Pre-Assessment Form

Step 1 of 11 - Your Details

Your Details

Please be aware that any information you provide in this pre-assessment form may be used in the final report. If there is information you think is important to share, but you do not want included in the final report, then we are happy to accommodate this, but please ensure you clearly indicate which information should not be included.

Name

First Last

Pronouns: (e.g. she, he, them)

Date of Birth

DD slash MM slash YYYY

Phone

Diagnosis (or suspected diagnosis)

Neurodivergence, mental health condition or other diagnosis:

Do you have any reports or medical information that might help your assessor?

Your Role

What would you like your Needs Assessment to focus on?

Work

Study

Work

Employment type

Employed full-time

Employed part-time

Self-employed

Apprenticeship

Unemployed

Other

please select all that apply

Place of work

Home

Office

Flexible

Other

please select all that apply

Job title:

Company name:

Please provide a brief description of your role and day-to-day activities:

What are the main strengths you bring to your work?

What are the main challenges you’re facing in work?

Study

Study type

GCSE

A-Levels

Further Education

Higher Education

Apprenticeship

Continued professional development

Other

please select all that apply

Place of study

Home

Institution

Flexible

Other

please select all that apply

School/college/university name (if relevant):

Current subjects/qualifications being studied:

Previous qualifications

Qualification Name

Subject

Grade

(please include if you think it is important for your assessor to know)

What are the main strengths you bring to your study?

What are the main challenges you’re facing in study?

Impact of Neurodivergence

Impact of Neurodivergence or health condition

Handwriting

Typing

Mobility

Reading speed

Reaching accuracy

Reading comprehension

Concentration

Processing speed

Short-term memory

Spelling

Grammar

Confidence

Time management

Organisation

Co-ordination

Mood

Motivation

Structuring written work

Physical health

Energy levels

Note-taking

Vision

Hearing

Communication

Sleep

Diet

Exercise

Mental health

please select all that apply

Support information

Do you have any existing support or strategies in place? If so please give further details.

Are there any equipment/support strategies that you are interested to learn about in the assessment?

What are your expectations of this assessment?

Do you need any access arrangements for the assessment?

Will anyone be attending the assessment with you?

Equipment

Please select any equipment you currently have access to:

Phone

iPhone

Android

Laptop

Windows

Mac

Chromebook

Apple tablet

Android tablet

Parent/Carer Details

(if Needs Assessment is for someone under 18 years old and parent is paying)

Parent/Carer Name

Parent/Carer Telephone

Parent/Carer Email

Consent

The purpose of the Needs Assessment is to determine what difficulties you may face in your work or studies due to your neurodivergence or health condition, and to consider what support can be provided to overcome those difficulties. In order to get the best outcome from this assessment, it would be useful to have the information requested in this from in advance of speaking with you. This will enable us to do any prior research needed, so that we can consider the full range of support available.

Some of the information we need to collect from you (such as details regarding your disability or condition), is “special category personal data” as defined in Article 9.1 of the General Data Protection Regulations [EU 2016/679] (“the GDPR”). In order for us to collect and process such data, we have to obtain your explicit consent.

I consent to you collecting and processing my personal data (which includes special category personal data) in accordance with our privacy policy.(Required)

I consent

I do not consent (Please note, if you do not provide your consent, then we will not be able to proceed with your needs assessment).

Please read our privacy policy

Please confirm that you have read and agreed to the terms and conditions(Required)

I consent

I do not consent (Please note, if you do not provide your consent, then we will not be able to proceed with your needs assessment).

Please read our Terms & Conditions

Has the assessment been paid by an external third party(Required)

Yes

(e.g. employer/parent/guardian/other)?

Please indicate your explicit consent that you are happy for us to send a copy of your report and discuss the findings of your report with the paying third party. (Please note, if you do not provide your consent for this then we may not be able to proceed with your assessment. This will need to be discussed with the paying third party. Please save your pre-assessment form, and contact [email protected] to decide how to proceed).(Required)

I consent

I understand that if I wish to cancel, postpone or re-arrange within 5 working days of the appointment there will be a cancellation fee of £100 due. If I fail to attend or re-arrange on 3 occasions then up to the full fee may be charged.(Required)

Yes

I consent to Aim Forward contacting me about their services and further ways to support me in the future.(Required)

I consent

I do not consent

Signature

Name

Signature

Date

DD slash MM slash YYYY

Needs Pre-Assessment Form

Your Details

Diagnosis (or suspected diagnosis)

Your Role

Work

Study

Impact of Neurodivergence

Support information

Equipment

Parent/Carer Details

Consent

Signature

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