Diagnostic assessment enquiry form

Organisational name

(if you are completing this form in a professional capacity)

Does your enquiry relate to An adult A child/young person

What is your enquiry?

Other (if applicable)

Your connection with autism

We would like to tailor our communications with you to ensure they are relevant to your interests.

What is your connection with autism? (Please tick all that apply.)

I am autistic

I am a parent/guardian of someone who is autistic

Someone in my family is autistic

I know someone who is autistic

I am a professional working in the field of autism

I have another connection with autism

I have no connection with autism

Prefer not to say

If you are completing this form in a professional capacity:

Do you support autistic people? If so, how much of your time involves specific responsibility for autism or autistic people? All of it Main focus (over 50%) Part focus (30%-50%) No specific or specialist responsibility

With which age range(s) do you work?

Early Years (0-4)

Primary (5-11)

Secondary (11-17)

Young Adult (18-25)

Adult (25-65)

Older Adult (65+)

Marketing permissions

The National Autistic Society would also like to keep in touch with you about our services, support, events, campaigns and fundraising.

We will only contact you in the ways you want, and we’ll keep your data safe. (See privacy policy for further details.)

To update your permissions, contact us on 0808 800 1050 or at supportercare@nas.org.uk

I agree to the National Autistic Society contacting me in the following ways

Post

Telephone

SMS text

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