PDA Contact Group: Membership

Membership Registration - Parent/Carers
M	indicates mandatory (required) fields

Name:

Address:

Postcode: Country:

Telephone:

e-mail:

Please check your email address, if it is wrong we will not be able to contact you!

How did you hear about PDA?

Do you intend to join the
PDA Contact Group Forum Board?

Yes No
Already joined: User name

This registration will entitle you to access the private Parent Members forums

Do you consent to your name and phone no. being given to other parent/carer members? Yes No

Survey

The information requested here will help build up a picture of the educational support
and other services available to children and adolescents with PDA and their families,
which will help us in future campaigning for provision of services

Name of child with PDA:

Date of Birth:

Please indicate which of these describes
the current status for your child:

	PDA diagnosed
	PDA suggested by a professional, but not yet diagnosed
	We believe our child has PDA and are trying to get a diagnosis
	Our child has another autistic spectrum diagnosis (Asperger, PDD), but we think PDA may fit better
	We've just found out about PDA and it seems to describe our child, we would like to find out more
	Other - please give details:

If your child has any other conditions,
please list:

Diagnosis
Name of Consultant giving PDA diagnosis:
Date of diagnosis:
Full name and address of Hospital/Clinic:
Does he/she take medication for PDA?	Yes No

Education
Full name and address of child's school:
Type of school:	Mainstream Local Authority Special Independent Special
Is your child without a school placement?	Yes No
Does he/she have a Statement of Special Educational Needs?	Yes No
What support does he/she receive at school?

Therapy
Does he/she receive any type of therapy?	Physiotherapy Psychotherapy Other	Speech therapy Complementary therapy
Please give details:

Do you receive help from Social Services?:
(e.g. respite, youth worker, holiday playschemes)

Yes No
Please give details

Please confirm your e-mail address:	M
When your input has been accepted a screen showing the information you have entered will be displayed. To prevent a duplicate submission, please wait for at least 15 seconds before clicking 'Send' again. A confirmation email will also be sent to the address you have provided. In the event of problems, please email the webmaster direct at the address shown on the initial welcome page.
The PDA membership secretary is a data controller under the Data Protection Act 1998. The personal data you provide in this membership form will be used for membership administration and for statistical and other purposes connected with the PDA Contact Group. Return of this form will be taken as your consent to such use. Membership details are not disclosed to third parties for marketing or other purposes not connected to PDA.