Register with the Berkshire Adult Autism Support Service

Thank you for your interest in registering for the NHS-funded Berkshire Adult Autism Support Service. Please can you answer some questions, so that we can best support you.

Name

Address

Postcode

Telephone number

Email address

 

Which council area do you live in? *

—Please choose an option—Bracknell ForestReadingSloughWest BerkshireWindsor & MaidenheadWokinghamOther

If you answered Other above, please give the council name

 

Do you have? *

An NHS autism diagnosisA private autism diagnosisA place on the Berkshire NHS waiting list for an autism assessmentNot have a diagnosis

 

Do you currently receive any support? (please tick all that apply) *

No support at presentSupport from family and friendsSupport from council care packageSupport for mental health needsSupport from the Probation ServiceSupport for addiction

 

Details of professionals who support me (if applicable):

Name

Their job (eg social worker, NHS mental health professional, care agency worker, probation officer

Telephone number

Email address

 

Message (if any)

 

I consent to Autism Berkshire storing my details on a secure database and contacting me about (please tick all that apply)

Support services for autistic adultsWorkshops for autistic adultsGroup activities for autistic adults

 

I am happy to be contacted by (please tick all that apply):

EmailTelephonePost

Your confirmation:

I understand that by submitting this form I am giving Autism Berkshire consent to store my data and use it to contact me in the ways that I have indicated and for analysis and monitoring purposes.

 

Privacy and data protection

Personal information you submit using this form will be treated as confidential and stored securely. See our privacy policy for more information.