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- AutismAutism usually manifests in the first year of life.
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Dimobi Childrens Disability Trust works tirelessly to support the needs of children with disabilities.
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About Us
Gallery
Referral form
Volunteer
Privacy
Contact

Autism Support Registration

Dimobi Childrens Disability trust offers a range of services to provide support and assistance to family members, carers, and professionals working with individuals with autism. Contact our special needs trust today for further information.

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Company

Your details

Step 1 of 4

Full name *

Phone *

Email *

Date of birth *

Age *

Gender *

FemaleMalePrefer not to say

Ethnicity *

Address & Post Code *

Emergency contact name *

Emergency contact phone number *

Relationship to participant *

Do you have any medical conditions we should be aware of? *

YesNo

If Yes, please provide details

Only if you answered Yes above.

Do you have any accessibility or support needs? *

YesNo

If Yes, please describe the support required

Only if you answered Yes above.

Does your child have - or do you suspect - autism or a learning disability? *

YesNoPrefer not to say

If Yes, would you like to share anything about this experience?

Optional.

Which topics are most important to you? *

What is Asperger Syndrome?What is Autism?Support GroupsParents' ForumRespite CareCounsellingLiving with AutismOther

Some sessions may include sensitive discussions. Do you consent to participate? *

YesNo

Would you like access to emotional support during or after sessions? *

YesNoMaybe

Do you give permission for photos/videos to be taken for project reporting? *

YesNo

Do you consent to Dimobi Trust storing your information for project purposes? *

YesNo

Signature (Full Name) *

How did you hear about this programme? *

Social mediaWord of MouthCommunity OrganisationGP / Health ServicePoster / FlyerOther

Your information is confidential and used only to deliver this programme. See our privacy policy.

Dimobi is a special needs and learning disability, autism provider based in Manchester.

Referral form