Skip to content

Neurodiversity
Assessment

About
- What We Do
- Who We Are
- Fees
- FAQs
- Policies
For GPs
- Referral guidance – England
- Referral guidance – Scotland, Wales, Northern Ireland
Signs of Autism
Assessment Process
- Autism Assessments for English-Speaking Adults Worldwide
Therapy
NHS Right to Choose
Resources
Contact

About
- What We Do
- Who We Are
- Fees
- FAQs
- Policies
For GPs
- Referral guidance – England
- Referral guidance – Scotland, Wales, Northern Ireland
Signs of Autism
Assessment Process
- Autism Assessments for English-Speaking Adults Worldwide
Therapy
NHS Right to Choose
Resources
Contact

Friend/Family Questionnaire.

Your details (person filling in this form)

Preferred pronoun

Email

Patient details

Date of birth

Patient Email

Gender

Male Female Other

If Other, please describe

Preferred pronoun

Questions

The following questions ask about the person you are completing this questionnaire on behalf of (“they”).

1. Current relationship status (tick all that apply)

Married Single Looking for a relationship Not interested in a relationship In a relationship with a partner Living with a partner Separated from partner Civil partnership Divorced

Other (describe)

2. Have they ever had a relationship with a partner? (a “couple” type relationship)

Yes No

3. Do they have any offspring (children / adult children) or step‑children?

Yes No

If yes, how many?

4. Do they live alone?

Yes No

5. If yes, what type of home do they live in?

A home they own A home they rent

6. Are they supported at home by professionals?

Yes No

7. If they live with someone else, who do they live with? (tick all that apply)

Their parents Their brother or sister Another family member A partner Friend(s) Housemate / flat‑mate (not a friend) A carer Supported accommodation Shared accommodation with people with disabilities

Other (describe)

8. Current employment status (tick all that apply)

In education / training A carer / have caring responsibilities A volunteer Employed / self‑employed full‑time Employed / self‑employed part‑time Unemployed and looking for work Unemployed and unable to work Retired

Other (describe)

9. If employed, which best describes their occupation?

Manager / Director / Senior official Professional Associate professional / Technical Administrative / Secretarial Skilled trades Caring, leisure and services Sales and customer service Process, plant & machine operative Agriculture / construction Not employed

Other (describe)

10. Jobs they have done in the past – please list (paid or voluntary):

11. Areas where they receive support (tick any that apply)

In the home (e.g. preparing food, personal hygiene) Employment (e.g. work tasks, co‑workers) Health care (e.g. medications, appointments) Finance (e.g. welfare benefits, managing money) Social activities (making friends) Lifelong learning activities In the community (e.g. transport, managing money) Further / higher education Organisation (planning daily activities) They do not receive support

12. Current physical health conditions (diagnosed) (tick all that apply)

Sleep problems Gastrointestinal problems Irritable bowel syndrome (IBS) Colitis High blood pressure Coronary artery disease / heart disease Asthma Epilepsy Cancer Arthritis Dementia / memory loss Diabetes Obesity High cholesterol None

Other (describe)

13. Are they taking any medication / therapy for a physical health condition at present?

Yes No

Please list details (if Yes)

14. Current neurodevelopmental / mental health diagnoses (tick all that apply)

Depression Bipolar disorder Anxiety Psychosis or schizophrenia Eating disorder Attention deficit hyperactivity disorder (ADHD) Obsessive compulsive disorder (OCD) Tourette’s syndrome Personality disorder Post‑traumatic stress disorder (PTSD) None

Other (describe)

15. Currently receiving any of these treatments for neurodevelopmental / mental health conditions?

Medication Psychological or Talking Therapy Other No

16. If yes, please describe treatment (type of medication / therapy)

17. Past diagnoses of neurodevelopmental / mental health conditions (tick all that apply)

Depression Bipolar disorder Anxiety Psychosis or schizophrenia Eating disorder ADHD OCD Tourette’s Personality disorder PTSD None

Other (describe)

18. Previously received treatments for neurodevelopmental / mental health conditions?

Medication Psychological or Talking Therapy Other No

19. Describe past treatment received

20. Have they ever had any problems with their nerves?

Yes No

21. Have they seen a professional about this (e.g. counsellor / psychologist)?

Yes No

22. If yes, list medication received in the past

24. Current concerns

25. Why are they seeking assessment at this time?

26. What brought them (or someone else) to think of Autism Spectrum Disorder?

They think they have an ASD Someone else thinks they have an ASD

27. Assessment adjustments they need provide (tick any)

Adaptations for hearing, speech or visual impairment Additional support during the assessment Support relating to learning disability

Other (describe)

Notes

The form has been submitted, thank you for your patience!

What Our Patients Say

Read feedback from our patients:

Thank you to Neurodiversity Assessments Ltd for such a quick referral and assessment process, Jason you were a fantastic assessor and made me feel comfortable and reassured at every opportunity you possibly could.

I really appreciate you all for your help on my journey of self discovery.

RW

Overall, how was your experience with our service?

Good

Please tell us why you gave this answer.

At the start of the process, there was an issue with sending forms between the GP and you. Once this was resolved, however, the whole process was quick and straightforward.

MH

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

The assessor made me at ease and was very understanding and supportive as I was extremely anxious.

LH

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

The whole process from the point of referral to the arrangements regarding interviews, questionnaires and assessment was faultless it wasn’t over complicated as some processes can be.

CH

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

Very professional and understanding

DP

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

Process was quick and easy, and the staff were incredibly understanding and accommodating.

KL

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

The service was very clear. The assessor was very understanding and put me at ease as I was not sure I wanted to talk to a stranger.

GP

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

Efficient professional and outstanding standard of assessors used.

CL

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

Quick and easy. Process was clearly explained and staff were friendly.

MG

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

Very professional assessor, kind supportive demeanour.

KD

Overall, how was your experience with our service?

Good

Please tell us why you gave this answer.

My therapist was kind and good.

JC

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

The process wasn’t complicated and was done efficiently and didn’t drag on forever. My assessor was very reassuring and helpful.

LJ

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

I was very anxious about getting diagnosed. Everyone was really kind and process was fast.

MF

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

Got in touch quickly with appointments. Tatum made me feel calm and as relaxed as I could be, really friendly.

JH

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

The experience was great – Jason did a fantastic job of explaining the process and carrying out my assessment.

MJ

Overall, how was your experience with our service?

Very good

Please tell us why you gave this answer.

Good communication, therefore I felt my assessment was in hand which was reassuring. Information about the process was clear. All interactions with clinicians were pleasant.

RL

Neurodiversity
Assessment

Blackmore CE, Nolan A, Stoencheva V, Greenwood N, Liu-Thwaites N, Maltezos S, McAlonan GM. Comparison of an online adaptation of the Autism Diagnostic Observation Schedule-2 with its in-person version in an adult autism diagnostic service. BJPsych Open. 2023 Mar 6;9(2):e51. doi: 10.1192/bjo.2023.24. PMID: 36876642; PMCID: PMC10044163.

Contact Us

Call: 0203 582 1352

Call: 07707 251 328

Or send us a message:

Name

Tel.

Email

Message

Copyright © 2026 Dr H Eli Joubert, all rights reserved.

Privacy Policy
Cookie Policy (UK)
Site by Idio

Privacy Policy
Cookie Policy (UK)
Site by Idio

Manage Consent

To provide the best experiences, we use technologies like cookies to store and/or access device information. Consenting to these technologies will allow us to process data such as browsing behaviour or unique IDs on this site. Not consenting or withdrawing consent, may adversely affect certain features and functions.

Functional Functional Always active

The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.

Preferences Preferences

The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.

Statistics Statistics

The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.

Marketing Marketing

The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.

Manage options
Manage services
Manage {vendor_count} vendors
Read more about these purposes

View preferences

{title}
{title}
{title}