Drive Ability North West Referral Form

Whether you’re a professional, or an individual wishing to refer yourself for one of our services, please use the form below.

If you need support to do this, call us on 01942 483713. 

Individual's title: *-MrMissMrsMsOther

Individual's name: *

Individual's date of birth (DOB): *

Individual's telephone: *

Individual's email:

Individual's address: *

Individual's postcode: *

Please select the support, advice or service we can help you with:

• Driving assessment
• Operating driving controls
• Vehicle access
• Wheelchair loading
• Returning to driving after illness
• Advice prior to starting driving
• Mobility scooter advice and support
• Children’s car seat and harness advice
• Referred by the DVLA
• Other

If 'other' please state:

If you have a medical condition that affects your driving please provide details:

Please tell us your current driving status:

• I have never driven
• I am a current driver
• Surrendered Licence
• Revoked License

Years of driving experience:

Licence type:

• Full licence
• Section 88
• PDAL
• Provisional

Licence number:

I have been advised not to drive until I have had my driving assessment:

• If yes, please tell us why using the fields below
• If no, please proceed to the type of vehicle question

Years of driving experience:

When did you last drive?

Who advised you not to drive? Please tell us their name, role and contact details below:

What type of vehicle are you driving/recently driven? Tell us the make and model:

Transmission:

• Manual
• Automatic

Any vehicle adaptations?

Your GP practice name and address:

GP practice telephone number:

GP practice email:

Have you or are you experiencing any of the following? Please tick all of which apply to you):

• Epilepsy
• Speech or reading changes
• Heart problems
• Mental health
• Allergies
• Memory Changes
• Reading or learning for new information
• Blackouts/absence seizures
• Dizziness, fainting or loss of consciousness
• Major operations
• Diabetes - Diet controlled
• Diabetes - Tablets
• Diabetes - Insulin
• Diabetes - Hypoglycaemia (hypos)

If you have ticked any of the above boxes, please give details in the box below:

Following this diagnosis, were you advised not to drive by a Medical Professional?

• Yes
• No

Following this diagnosis, have you informed the DVLA?

• Yes
• No
• I’m not sure if I need to

Referring professional’s title (if applicable):-MrMissMrsMsDrOther

Referring professional’s name and designation:

Referring professional’s email:

Referring professional’s telephone:

Referring professional’s address:

Referring professional’s postcode:

Trust/Hospital/Service:

Referring professional’s referral reason and additional information (including cognitive):

Submit

We will use your address to ensure that we are your closest Driving Mobility centre.

If there is a centre closer to you, you will be given the opportunity to select this one.