First Contact Form
Before attending a consultation visit, I would like to have just a few bits of basic information to help me prepare for the visit. This information will not be shared with anyone else. You do not need to sign in before completing it. Feel free to contact me first before completing the form.
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Name of parent *
Please can you provide an email address where I can contact you to make an appointment or discuss your concerns? If you prefer that I phone you, you can also leave a phone number. *
Where did you hear about Celeste4Autism? *
Can you tell me a little bit about who you are referring? 
Name? Age? Gender? 
 *
Does he / she have any special interests? What are these? *

What are their greatest strengths? *
Which behaviours or needs are you most concerned about? *
How concerned are you about their language? *
No concern
Great concern
How concerned are you about their social skills? *
No concern
Great concern
How concerned are you about their emotional regulation? *
No concern
Great concern
How concerned are you about their ability to adapt to changes? *
No concern
Great concern
How concerned are you about their safety or danger awareness? *
No concern
Great concern
What are you hoping to get from my service? (You may tick more than one option) *
Required
Which days and times are you usually available? (for the consultation visit and for possible follow-up support)
Is there anything else that you feel would be important for me to know about you, your child or family? (Medical conditions, allergies, risky behaviour, a dog that might eat me! ...)
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