New Individual

Devon Autism Alert Card Application

To be eligible the cardholder must:

  • Live in Devon (any part)
  • Be over 10 years old (if your child is 10 or below we have an alternative support package) - If the cardholder is aged between 11-16, then an adult needs to apply on their behalf. If this is difficult, then please contact us and we will discuss the situation.
  • Be diagnosed as on the Autism Spectrum OR self declared with the intention of obtaining a diagnosis and have an appropriate Autism Quotient score (the AQ test is here: www.aspergerstest.net/aq-test/)

First issue free, replacement cards cost £3 + p&p If your card is lost or stolen, please report as it soon as possible Please send your completed form to:

Dimensions For Living
Brookside Dell, West Hill
Ottery St Mary, Devon
EX11 1UD

If you would like help in filling in this form then please feel free to contact us

Tel: 07421 77 88 09
Email: autismcard@dimensionsforliving.org
Webpage: www.dimensionsforliving.org/x8
Facebook: Dimensions For Living

We can help you over the phone or arrange a volunteer to guide you through it face to face

Please tick one only

Details of Intended Cardholder

Details of person applying on behalf of intended cardholder

Please enter details of the Autistic Spectrum diagnosis

Please tick ONE only

Diagnosis Details

Please add to the nearest month and year

If you have not yet had a diagnosis

OR

you can take the AQ test here: www.aspergerstest.net/aq-test/

You need to check this box so we can know your progress

Name and address of place where you are receiving or will apply for a diagnosis

Are you experiencing difficulties obtaining a diagnosis? Contact us to see if we can assist

 

You need to tick the box below to receive a card

Please read and tick this box. We need your permission to keep your personal information. If you do not want us to keep this information, then we can not keep track of who we have issued cards to and so we can not accept your application.
All cardholders (or applicants on their behalf) will have access to their personal profiles on our site, and be able to update information.

By submitting this application I consent for the information to be held on a secure database by Dimensions For Living.

You can choose to tick the boxes below

Checking this box means that we can work with the Devon Councils and Devon & Cornwall Police on the need to provide various support services for the Autistic Community and training for those who come into contact with it.
If you are applying for yourself then put your name here. If you are applying on behalf of someone else then please put your name here (not the intended card holder's name)

Fully supported by Devon & Cornwall Police, Devon County Council, Plymouth City Council and Devon Link up. Go to www.dimensionsforliving.org/xq for full details.