Adult Enquiry Form Prior to Consultation

    If you are in the workplace, or unemployed and would like help with skill development please complete this form as fully as you can and return it to the Centre. It will help us to help you. The answers are entirely CONFIDENTIAL to Centre Staff and Professionals directly concerned with you.

    If you find this form difficult to complete the Centre will help you.

    First Name

    Surname Name

    Date of Birth

    Title MrMrsMissMsOther

    Your Address

    Postcode

    Home Telephone

    Work Telephone

    Mobile Telephone


    Employer
    Employer’s Address
    What is your present job?
    Please list the jobs you have had
    If you are not in work, what work or training are you interested in?
    What do you hope we can help you with?
    How can problems affect your work?
    What are your concerns and view of these problems?
    Does your Human Resources Department know that you have contacted us? YesNo
    If yes, please provide name and contact details:
    Have you applied to Access to Work? YesNo
    Do you have a needs assessment report? YesNo
    If yes, please provide a copy of the report
    Have you been assessed by an Educational Psychologist or Specialist teacher? YesNo
    If yes, please provide a copy of the report
    Medical History: Please give information regarding any illnesses or conditions that we should be made aware of
    Are you taking medication currently? YesNo
    If yes please provide details:

    Important Notice
    Whilst great care is taken in all matter, the Centre cannot accept liability or responsibility for any advice given by the professionals to whom the Centre refers the child/adult (assesse).
    The Centre may, in its absolute discretion and after the appropriate permissions have been obtained, maintain, for its administrative purposes only, a confidential file of records relating to the assesse including a copy of this questionnaire and any reports. The centre is at liberty to destroy such files or to charge a reasonable sum to retrieve any such files that have been retained.
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