Enquiry Form | Adolescent and Adult Diagnosis - 13 to 30 years - Autism Association of Western Australia

Please provide information relevant to the person seeking assessment.

Name*

First Last

Date of Birth*

Age*

Gender

Email*

Phone*

Address*

Home Address Suburb State Post Code

Primary Language

Do you require an interpreter?

Australian Permanent Residency Status*

I live:*

Have you been previously assessed for Autism Spectrum Disorder?*

Details of Parent or Guardian for inviduals aged below 18 years of age or for those under guardianship.

Name

First Last

Phone

Address (if different from above)

Home Address Suburb State Post Code

Spoken Language

Do you require an interpreter?

Relationship to Individual seeking assessment

How did you find out about our clinic?*