The Assessment Team Pro Bono either ASD or ADHD Assessment Request Form

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Please ensure that the school and parent(s) / carers are aware that this request has been made. PLEASE NOTE - requests are allocated randomly, and completing this form does not guarantee that your request will be picked.

Email *

Child's Full Name *

Which school year did your child start in September 2023? *

Year 5

Year 6

Parent or Guardian Name *

Parent or Guardian email address *

Parent or Guardian contact phone number *

Name of school attended *

Postcode of school attended *

Please confirm the date that school agreed to this referral *

YYYY

Which District / Borough do you currently live in? *

Dacorum

St Albans

Watford

Three Rivers

Welwyn Hatfield

East Herts

Broxbourne

North Herts

Stevenage

Hertsmere

Out of county, but have a child attending a school in Hertfordshire

Name and job title of teacher supporting this request *

Direct email address of teacher or SENCo who is supporting this application *

Is your child currently eligible for free school meals (NB we will require proof of eligibility to enable access to this service) *

Yes

Eligible but not currently claiming free school meals

Which NHS assessment are you currently on the waiting list for? *

ADHD

ASD

Both

Currently not on waiting list

Is your child currently being supported by CAHMS? *

Yes

Which assessment would you like to put forward for *

ADHD

ASD

Are there any other factors we should be aware of?

Send me a copy of my responses.

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