Vehicle and Passenger Access Assessment Form – Drive Ability North West

Whether you’re a professional, or an individual wishing to refer yourself for vehicle and passenger Access assessment/support, please use our online referral form below:

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: *

Individual's emergency contact name: *

Individual's emergency contact telephone: *

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

• Vehicle access
• Wheelchair loading
• Regaining independence after illness
• Advice on what’s available to help me maintain an active lifestyle
• Referred by the Motability or other charity
• Other

If 'other' please state:

If you have a medical condition please provide details (including dates if possible):

Can you weight bear?-YesNo

Can you walk unaided?-YesNo

If no, please provide details below:

Do you ever use a wheelchair or scooter either at home or out of doors?-YesNo

If yes, please provide details (make, model and usage) below:

Do you qualify for the Motability Scheme?-YesNo

What type of problems are you experiencing? Please tick more than one if appropriate:

• Getting in or out of the vehicle as a driver
• Getting in or out of the vehicle as a passenger
• Loading a self-propelled or attendant propelled, manual wheelchair
• Loading an electrically powered wheelchair
• Loading a scooter

If applicable, please tick where are you accessing your vehicle?

• Drive
• Roadside
• Other

If 'other' please state:

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:

Has the referrer completed any cognitive testing with the individual:-YesNo

If you have selected yes, please give details in the box below (tests used, score, etc):

Referring professional’s referral reason and any additional information:

Privacy policy *

• I confirm that I have read and I consent to Bridgewater's privacy policy

Submit

Please note: If you want a copy of your referral please save your details before pressing submit. We are unable to send copies of the referral once submitted.

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.